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ant By: Gregg [billing & Testina, Inc.; <br />UIV/ iVU1 TUE U9:99 FAa 19. "82355 <br />09-19-2®01 07:43RM FROM <br />925 313 0302; <br />GROUNDWATER-- <br />TO <br />Sep-18-01 11:13; Page 3•:� <br />X03 <br />192513272029 P.02 <br />San Joaquin County Ertvlrorlmental Health Services, Unit IV Well Permit Application $uppiement <br />JOB ADDRESS'«�1� ^� �a �n S4: juldU kU-PFERMIT SR#: _ <br />r <br />LICENSED CONTRACTORS DECLARATION LC <br />I herepy aftlrm that I am owsed under the provisions of Chapter ® (Commencing wfih Sectiorn7000) of Division <br />3 of trig Business and Professions Code and my license Is in full force/and effect. <br />Licersa ; Cr7 Expirstion DMe:�l <br />n / 1 <br />Titlayyst-QBl/%.�!lQAQg�. <br />Printed narne: <br />WORKERS' C v1PENSATION DECLARATION <br />I'lhereby affirm under penalty of pedury one.of the following declarations: (CHECK ALL THAT APPLY) <br />I have and will maintain a certificate of.conse-nt to self -Insure for workers' compensatlon, as provided for by <br />Sectlon 3760 of the Labor Code, for the performance of the work for which this permit Is issued. <br />2(l have and WHI maintain Y�orkem' compensatfon insurance, sas required by Section 3700 of fhe Labor Code, <br />for the performance of this work for which this permit is issued. My workers' compensation Insurance <br />carrier and policy numbers are: <br />Carrier: �G�- 1Ltede Policy Number; <br />I certify that In the perforrhance of the work for which this permit Is Issued, I shall not employ any pereon In <br />any manner so as to became subject to Ow workers' compensation laws of California, and agree that if I <br />should become subject to the workers' compenaatlon provisions of Section 3700 of the Labor Code, I shall <br />rortt,with comply with those provisions. <br />Date:L 8' �l ! Signature: <br />Printed Name: <br />WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE 13 UNLAWFUL, AND SHALL SUBJECT <br />(7EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br />00,00.), IN ADDITION TO THE COST OF COMPENSATION, INTEREST, ATTORNEY'S FEES, AND DAMAGES AS <br />PRO%IDEO FOR IN SECTION 9905 OF THE LABOR CODE. <br />1, /L1T�l�f9 J' ��r1e�(C-57 licensed authori"d rmpresontativo); hereby <br />authorize <br />• r <br />to sign this San Joaquin County Wall permit Application on my behalf. I understand this authorisatlon is valid for <br />ono (1) year and Ls limited to the work plan datFd on the front page of this appllrraltion. <br />7-2000 <br />TOTAL P.02 <br />