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JA[71V@1q0 San Joaquin County Environmental Health Services, Unit Iv wen rermii HPPucauUll ♦iUPPIVIIIVIIL JOB ADDRESS: 1�CbT 120 PERMIT SR#: OZ� 2{39 LICENSED CONTRACTORS DECLARATION I hereby affirm that I am licensed under the provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code and my license is in full force and effect. Expiration Date: 10 12 00 Contractor. aZD-,-QUC L� ��•�y 1 iture: Title: Operations Manager ld name: Ver Chapman WORKERS' COMPENSATION DECLARATION I hereby affirm under penalty of perjury one of the following declarations _ I have and will maintain a certificate of consent to self -insure for workers' compensation, as provided for by Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. X I have and will maintain workers' compensation insurance, as required by Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. My workers' compensation insurance carrier and policy numbers are: Carrier: Alaska National Ins. Policy Number: _ I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to become subject to the workers' compensation laws of California, and agree that if I should become subject to the workers' compensation provisions of " tion 3700 of the Labor Code, I shall forthwith comply with those provisions. Date: 10112100 Signature: Printed Name: Vera Chap WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS PISECTION 37 6 OF THE DDITION TO THE COST N OFCOMPENSATION, NSATION, INTEREST, ATTORNEY'S FEES, AND DAMAGES AS PROVIDED FORCODE (C-57 licensed authorized representative), hereby to sign this San Joaquin County Well Permit Application on my behalf. I understand this authorization is valid for