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04/04/2002 THU 09:04 FAX <br />Unit IV WeN Permit Application Supplement <br />San Jl aquln County Environmental Health S,eryices, / <br />JOB ApDRESS: 2� i ` ' L J- PEFMT Skf*' � U! <br />LICENSED CONTRACTORS DECLARATION (LCD) <br />I hereby affirm that I am licensed under the provisions of Chapter 9 (commencing with Section 7000) of DivisrOn <br />3 of the Business and Professions Code and my license is in full force and effect. <br />r <br />License #: j0 a,4y1 Expiration Date: Z"; <br />Date: _, W—o <br />Signature: <br />Printed name: <br />ntractor: C <br />,FAY -/)Title: Cta!�c/l�Jli <br />WORKERS' COMPENSATION DECLARAMN <br />r,9 <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 />�Scction 3700 of the Labor Code, for the performance of the work for which this permit is Issued. <br />✓/ l 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' compensation insurance <br />carrier and policy numbers are <br />Carrier: Ll Policy Number: -� <br />14 certify that in the performance of the work for which this permit is issued, 1 shah not em <br />ploy any person In <br />ahy manner so as to become subjact to t? -,e workers' compensation laws of 03!if0rni3, and agree thot if I <br />should become subject to the workers' Compensation provisions of Section 3700 of the Labor Code, I shall <br />forthwith corrply with those provisions. <br />Date: Signature: <br />Printed Name: -lA... ` I-.. YLI <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 />($400,000.), IN ADDITION TO THE COST OF COMPENSATION, INTEREST, ATTORNEY'S FEES, AND DAMAGES AS <br />PROVIDED FOR 1N SECTION 3706 OF THE LABOR CODE. <br />to sign this San Joaquin County Well Permit APPI <br />i understand this authorization iq valid for <br />one (1) year and is Ilmited to the work plan dated on the front page of this Ap tication- <br />''ilOi�� IUdPS=L l EE6 i—C"1-'J l <br />