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INo r qp � p 'e r <br />K .v' r..i r:1Y7 4� � �'v.,� <br />FAX N0. : 19166388613 Jun. 21 2002 02:19PM P1 <br />_ C_;C� 5 _"0 --- - . <br />San Joaquin County Environmental Health Department Unit Iv Well Permit Application Supplement <br />JOB ADDRESS:., x5 G.!46m6e PI~RMIT SRM 0`x305 `!0 <br />LICENSED CONTRACTORS DECLARATION (LCD) <br />I hereby affirm that I am licenctid under ti'ra provisions of Chapter 9 (corninori6rig with Section 7000) of Division <br />3 of the Business and Professions Code and rity licorwu ib i i full force and eff*wt. <br />License #: _ J S- -7'5 _ _ Pxpiration Data: <br />Data: 5,,�_��.#z,r.ti►^� �2•IL(.�nfi,---��_ <br />SPgnat _------ Tijfa:��d'o^"n' �%t-�•.r-�d'td� <br />WORKERS' COMPENSATION DECLARATION <br />I hr5reby Atfirm under penalty of perjury cine of the following declarations: (CHECK ALL THAT APPLY) <br />_ I have and will maintain a certificate of consent to self -insure for workers' (,,ompEansation, as provided for by <br />action 3700 of they Labor Code, for tho performance of the work for which it is permit is issued. <br />1havn and will m,-lintain warkt)rs' campenaation insurance, 8s required by Soction 3/00 of the tabor Cade, <br />for the porformance of the work for which this permit is iss(md. My wurkars' compensation 1r7so1*ar10 <br />08Mer and policy numbani are: <br />ZI <br />rrier: 14'LrFj ��? �..,S ---- —�Policy Number: Z2 WOV4e?27Y1 <br />cartify that In the pe3rformBncei of the work for which this permit is Issued, I $kali not employ any perr,on in <br />any manner so as tO IMCOMH t;ubjt$ct to tl,ic� workers' compensation laws of California, and agree that if I <br />should become subjecd to the workers' compensation provisiams of Section 3700 of the Labor Codd. I shall <br />forthwith comply with !hose prnviaions. <br />Crate: 416- 2 /'Q ?. Signatures <br />Printed Nam—. <br />r cwrt,w 14- '601W--•••• Ci0�1� <br />WARNING: FAILURE TO SECURE WOIRKERSCOMPENSATION COVERAGE 16 UNLAWFUL. AND SHALL SUetJECT <br />AN EMPL.oYI:R 1'0 CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND nOt 1 ARS <br />($100,000.), IN ADDITION TO THE COST OF COMPENSATION, INTEREST, ATTORNEY'S FEES, AND DAMAGES AS <br />PROVIDED FOR IN SECTION 3706 OF THE LABOR C00r1 . <br />r•i /�'J''d � ` <br />hereby authorize (print <br />Jlt1.r cfv- r � <br />G 6 rr z -L -r e,.r <br />ofC-4Y licensed authorized roproasontative), <br />to slgn thin San a&Ag11f r County We11 Pormit Application on my behalf. I undoratand thea Authculzatlon I.* valid for <br />one (1) year and in limitod to tha work plan dated on than front page of this application. <br />t <br />TO/T0 39vd Noi>iDol5 199 <br />Cillo 9--h!- <br />8TTTL9bWl36 6P:ET ZOOVIZ/00 <br />