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01/02/02 WED 13:49 FAX 1 916 861 0430 SECOR-SACRAMENTO <br />-Wi e&.V,c "ry J�J:1V 1'AA <br />San Joaquln,County Environmentajll Health Services, Untt IV Well Permit Applioativn Supplement <br />JOB ADDRESPERMIT SIR#: <br />0YA I <br />LIC NSED CONTRACTORS DECLARATION (LCD) <br />I 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 and effect, <br />License #: Expiration Date: _��► Il �� <br />Date:Con ctor.an <br />Signature:, „ Title: <br />Printed name; A Vi {At.Au <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 />v/ I have and will maintain workers' compensation insurance, as required by Section 3700 of the Labor Code, <br />for the performance of the work for which this permit is issued, My workers' compen5alion insurance <br />carrier and policy numbers are: .•7 <br />Carrler: �� �?d Policy Number. <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 I <br />should become subject to the workers' compensation provisions of Section 3700 of the Labor Code. I shall <br />forthwith comi1aly with those provisions_ <br />Date: , �. V Signature: <br />Printed Name: l_MLJ f -f 111LI-JeA-4 <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.), 1N ADDITION TO THE COST OF COMPENSATION, INTEREST, ATTORNEY'S FEES, AND 13AMAOES AS <br />PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. <br />to sign this San Joaquin County Well Penult <br />one (1) year and Is Ilrmlted to the work plan dated on the front page of this application. <br />V.4-'VJ*,r,�,rL;Ik;��- ?D box 4io I\SkAbr1, `11 1404 <br />U002 <br />2 002 <br />rsenai hereby ereby <br />llov-alidfor <br />0 0 <br />�,y <br />