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11/02/99 14:14 FAX <br />JOB ADDRESS: <br />inS rvIces, Unit IV Well Permit Application Supplement <br />1 n T T. PERMIT SR#: <br />owwn- + CR <br />LICENSED CONTRACTORS DECLARATION (LCD) <br />1 hereby affirm that I am licensed under the provisions of Chapter 9 (commencing with Section 7000) of Division <br />3 of the Business and Professions Code and my license is in full force nd effect. <br />License ft: /r10 �'7 Expiration Date: 1,30100 <br />Date: 1 Contractor \// WA i 8 1)"r MI -VI rn C <br />Signature: Title: Aj <br />Printed name: <br />WORKERS' COMPENSATION DECLARATION <br />I hereby affirm under penalty of perjury one of the following declarations: (CHECK ALL THAT APPLY) <br />I have and will maintain a certificate of consent to self -insure for workers' compensation, as provided for by <br />^/ Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. <br />y I have and will maintain workers' compensation insurance, as required by Section 3700 of the Labor Code, <br />T for the performance of the work for which this permit is issued. My workers' compensation insurance <br />carrier and policy numbers are'. <br />Carrier: GpIden _gQ c Policy Number: Illk%C'S� � U5 <br />1 certify that In the performance of the work for which this permit is issued, I shall not employ any person in <br />any manner so as to become subject to the workers' compensation laws of California, and agree that if 1 <br />should become subject to the workers' compensation provisions of Section 3700 of the Labor Code, I shall <br />forthwith comply with those provisions. <br />Date: <br />Signature: <br />Printed Name: <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 />($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 CODE. <br />L11/1W//1 (2- (C-57 licensed Authorized representative), hereby <br />authorize <br />to sign this San Joaquin County Well Permit Application on my behalf. I understand this authorization is valid for <br />one (1) year and is limited to the work plan dated on the front page of this <br />M <br />