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11/15/2001 14:02 2094683433 FIFTH FLOOD, PAGE =?3 <br />` 1 - <br />San Joaquin County Environmental Health Services, Unit IV W611 Prmit Application Supplern nt <br />JOB ADDRESS.=;'/D �j L PERMIT SR#: <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 Code and my license is in full force and effect. <br />License #: �q 9 7 S Expiration Date: O/- 3/-63r--. <br />Date: O S- OV -02 - <br />Signature: t/-uL <br />Signature <br />,Contractor <br />l�rS i <br />Printed <br />Lt�xr�'dt�- <br />Printed namel__A f Cr'ffiLd <br />kVL-51' i_/1tza4.11- 25"444_16 <br />,b t�crt�ri� <br />WORKERS' COMPENSATION DECLARATION <br />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 />_1Z11have 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: //FRTSfr6ll a Policy Number: 22 Wh✓6/Z7 y / <br />AZIcertify 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 e Labor Code, I shall <br />forthwith comply with those provisions. <br />Date: <br />46,6-7 0 1" Signature <br />Printed Name: ` c61-Xh`'O 41 <br />WARNING: FAILURE TO SECURE WORKLRS' C''0 MNtNSAT!ON COVFF_akG iS UNLA iiii uU, ..SND 51+,i�•L L suBJECT <br />AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLA7.5 <br />($100,000.), IN ADDITION TO THE COST OF COMPENSATION, INTEREST, ATTORNEY'S FEES, AND DAMAGES AS <br />PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. <br />I��r ct!/}7'O `✓,e/4' (signature ofC-57 licen3od authorized representative), <br />here by authorize (print name) Ofr /cib �iK- �rL <br />to sign this San Joaquin County Well Permit Application on my behalf. I 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 />5-17-20001 MI <br />