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FROM : West Hazmat FAX NO. : 19166388613 Nov. 13 2001 02:2-'M P2 <br />1111JI/youl 11,1:0H 10y4b' '" FTFTH FLOOR RAGE 03 <br />^San Joaquin County Fnvlronmental H®alth Services, Unit IV Well Permit Application Supplement <br />JOB ADDRESS:r-(Q� � /,� S ERMIT SR#: <br />LICENSED CONTRACTORS DECLARATION (LCD) <br />I hereby affirm that I am fironsed under the provisions of Chapter 9 (commencing with Section 7000) of Division <br />3 of tho Business and Professions Code and my Jimnse is L-, fult force and effect. <br />Liconse N: _ .L L 7 _ Expiratpon <br />Ditto; -Ji-is -8�- <br />C:ontrdctor: <br />Signature, Title: f <br />Printed name: L <br />�Q +� <br />WORKERS' COMPENSATION DECLARATION <br />I hereby affirm under penalty of perjury one of the fallowing declarations: (CHECK ALL THAT APPLY) <br />I havo 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 />have and will maintain workers' compensation insurance, as required by Section 3700 of tho Labor Code, <br />for the performance of the work for which this pormft is issued. My workers' compensation Insurance <br />carrier and policy numbers are: <br />7C Tier: _,,,� 1�6 -:D — Policy Number: �Z W 6 ✓,C? Z7 `-i I <br />✓_ 1 certify that in the performance of the work for which this permit is Issued, I small flat em <br />- ploy any person In <br />any manner so as to become subject to the workers' compensatlon laws of Califomia, and agree that If I <br />should become subject to the workers' compensation provisions of Section 3700 of the ode, 1 shall <br />forthwith comply with those provisions. <br />Date: 11-13-41 Signature:Z �, <br />C <br />_ <br />Printed Name: I"tfvrW -- µ - <br />WARNING: FAILURE TO SEGURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL. AND SHALL SUBJECT <br />AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br />($1 D0,000.), IN ADDITION TO THE COST OF COMPS BATU)- I, -INTEREST, ATTORNEY'S FEES, AND DAMAGES AS <br />PROVIDED FOR IN SECTION 3706 OF THE CODE. <br />1'>Ittr"' ' (■l9nature ofG-07 licensed authorized representative}, <br />1116, ,izo (print name)- 1J,6 6)1- <br />i0 <br />Jrio sign thio San Joaquin County Wall Permit Application on my behalf. I understand this authorization is valid for <br />one (t) year and IK nmNud to thv work pian dated on the front Paige of this appli"Ilon. <br />5-17-x0001 MI <br />