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AJAR lling & Testing, Inc.; 925 313 0302; Jul -27-01 16:14; Page 2/2 <br />San Joaquin County Environmental Health Services, Unit (Yzwfl it Application Supp{Qment <br />JOB ADDRESS: � 0/' T SR#:f�2,G'W <br />(tea e. v1 -an <br />i1� <br />LICENSED 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 Cade and my license is in full force and effect. <br />License # �10D "7 Expiration Date: <br />Date: �j %1 7/ .Contractor: <br />Signature: <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 />_ l 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 />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: <br />/Qar-k.r~ Policy Number. <br />ZI 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 taws 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 comply with those provisions. <br />Date: �C3� 7 d/ 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 />?SRO ,1i#0 00.), I OR N SECTION.3706 O <br />ADDITION <br />TO THE <br />�TH�BOR COMPENSATION, INTEREST, ATTORNEY'S FEES, AND DAMAGES AS <br />(signature ofC-67 licensed authorized representative), <br />hereby a uthorizs (print name]-_ <br />to sign this San Joaquin County Well Permit Application on my behalf. 1 understand this authorization is Valid for <br />one (1) year and is limited to the work plan dated on the front page of this application. <br />8-17-2000 1 MI <br />