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10/23/2001 TUE 13:.,j FAX <br />San Joaquin County En4ironmental Health Services, Unit IV <br />13'ermit,Appl <br />RMRE <br />a--.� �._� <br />n Supplement <br />Z:79S <br />with .$e tion.700��$6Di�tion <br />Io wltn S�ectlon o IVI: <br />License <br />sense . <br />ereby affirm that I have a c"ted <br />r�gr�t� 61t1�t'CS1Workers' Compensation <br />Durance, or a certified copy ec. 3 a Cj <br />fl enalty of perjuryLpomof the � eclaca ons: `� K ALL TMAT APPLY) <br />I have and wi I maintain a certificate of consent to s(elf-insure for or workers' compensation, as provided for by <br />Ce?tipMfrAyLt�Sgjs6gde, for the performance of the work for which this permit is issued. <br />Ce Ined copy is filed with the County Building Inspection Division <br />71 have and will maintain workers' compensation insurance, as required by Section 370U of the Labor Code, <br />for the(pEFRMt0jWTEFfOV <br />carrier and policy numbers are: <br />its section n e Piet , if the permit is for one hu dre dollars <br />erti" �e-we# ier�r#isk�-ila+s�e 1 ih r <br />to become subject to the Workers' Compensation Laws pf ChaJifomia. p oy y p <br />_ I certify that in the performance of the work Tor w is Is permit is issued, I shall not employ an erson in <br />ate any manner so as to become sub] workers' compensation laws of California, and agree that if I <br />s ou ome su a wornr com n <br />S <br />N TICt � wl�a�rgh�{R�i�>l'ii3� Certificat f Exemption, y shout �b ome subject to the Worker; <br />C mpensati0 P gi i th Labgg Cod€ �eou mu t f g�e G mp ith 'h' pro ` i r this permit shat <br />b i igna u <br />Printed Name, JG { <br />WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL SUBJECT <br />AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br />PT <br />10106,000.), M ADDffION TO THE COST OF COMPENSATION, INTER.E$T, ATTORNEY'S FEES, AND DAMAGES AS <br />PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. <br />:� iC-57 licensed authorized representat've}, her y <br />n � , <br />duihflrizL� <br />to sign this San Joaquin County Well Permi 41pplication on my behalf. I understand this authorization is srali 4or <br />one r, 4nd is limited to the work plan dated on the front page of this application. <br />