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A Vr4 I @ I Afl: 03PM <br />Aug 15 03 03:25p <br />HP LASERJET 3200 <br />Horizon Env. Inc <br />916 939 2172 p.2 <br />San Joaquin County jEnvironmental Health Department Unit N Wsll Permit Application Supplement <br />JOB ADDRESS: 1+40 f�sf � Yl PERMIT SR#: <br />LICENSED CONTRACTORS DECLARATION (LCD) <br />I hereby affi,m that I am lic=nscd under the prcvisians of.ChWt; li•9 (Cunmenrong witn Section 7010) ottiivision <br />3 of the Business and Professions Coderarrorry license is in full force and effect. <br />Licenses # (� `� t !1 Expiration Date: /,o rj0 `T <br />Date:I S 7 Corm�ctor L11� fi'� <br />I Printed narne: <br />WORKI=RS' COMPENSATION DECLARATION <br />I hereby affirm under penalty of perjury one of the following decla,W: ons. (CHECK ONE) <br />I novo and will maintain a cert fio3te of corsent to *elf-inisure, for workci s' curnNensatil as provided for j <br />by Sel 3700 of the Labar Code, for the WOfrnartce of the wOrll which this permit is issued. ` <br />-14 _ l havp and will mairtain wcrkars' conpansation insurcncc, as regiired by Section 3700 of the LdLier Code, <br />for the pe -form ance of tfsvil for which tf+rs permit IS isSLed, My workers' compensation insurance <br />carrier and poliiny numke's are <br />Carrie. +�� Policy Number: -r�� <br />Carrier, f ? <br />I cert fy that in the performance of the wo,k for which this aermit is irsued I shall rill crnpioy any person in <br />any manner se as tQoeco�r.e sunject ta.the_workers c-=T:peasstioalaves laws -of Calfornia, and agree that if I <br />should become sobjectto the work l`S`-Mmpensat'on provisoes of -Section 37CO of the Labor Code; I shall <br />forthwith comply with those provisions <br />Date: Signature: <br />Printed Name: 'Z <br />WARNING: FAILURE TO SECURE WORKER-S`COM-PENSATION GQVEKAGE15UNLAWFUL, AND SHALL SUBJECT <br />AN EMPLOYER'i U CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br />(;100,000.), IN ADDITION TQTI C-CO$rOFC0VFENSATT0N, INTEREST, ATTORNEY'S FEES, AND DAMAGES AS - <br />PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. <br />ALITHORIZATI-ON-FOR OTHER-TkAtil 57 SIGNING PERMrr APPLICATION <br />a_,u'& C4�— (signature arc-5TTcenseclaruthorized representative). <br />hereby authorizes ttra <br />(print S r >`f Z— <br />to sign this San Joaquin County Well Parmit Application on my behalf. I understand this alith.orization is valid for <br />one (t j year and is limited to the work plan dated on the front page of this application. <br />p.2 <br />