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A <br />i1EC 19 '00 <br />P, ! rl, <br />P.2'— <br />San Jc;jquirl.County Environmental Health Services, Unit IV Wolf Parmlt Appncat,on supplamont <br />JOB ADDRESS: PERMIT SR#' 4 � <br />LICENSED CONTRACTORS DECLARATION (LCD) <br />I hereoy af`rm that I em licensed undar the provsio: c of Chapter 9 (commencing with Section 7000) of Division <br />3 of the B.jsiress and Frofess'ons Code and my I'cerse is in Nil force and effect. <br />�icense #:.7209Q�i Exp'ratlon Dais. <br />Cate: l:2 I to DO contractor: V, l</ ��• ��� 1 c I <br />Signature: A2L Title: <br />Prin•e0 name:...-1�-���k - <br />i <br />WORKERS' COMPENSATION DECLARATION <br />I ^,ereby affirm Under per Sliy of per ury one of t^.e fol!owir.g declarations; (CHECK ALL THAT.APPLY) <br />a I have gnd wail ma!ntaln a cert,flcz'e of consent to se ,,.Insure for Y vksrs' compensation, 2s proV:ded for by <br />Section 37.00 of the Labor Code, for ms performanc: of the wDrk nor which this permit is issued. <br />�1•`9ve ens wlil rneinia'n workers' compensation ire.,ince, as rewired by Section 3700 of the :.abar Code.; <br />for the performance of the work for which this permit Is Issued. My workars' compensation insurance <br />c9rder and policy numbers are: <br />Carrier. Policy Number:5.3.x;1- 94 <br />I 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 becoma subject to the worRers' corn pensatic r•, taws of Californle, end agree That If I <br />should become sub)eot to the workers' compensation prov!slons of Se,.tlon 3700 of the Labor Code, I shall j <br />forthwith vorrply w!th those provlslons. 1 <br />Date; j� ��d,��•� _ Slen.atUra, <br />PrintedIlamet > Legr� Vc�!eP✓ <br />WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAOE IS UNLAWFUL, AND SHALL SUBJECT <br />I AN EMPi.OYER To CRIMINAL PENALTIES AND CIVIL FINES UP 70 ONE HUNDRED THOUSAND DOLLARS <br />bC,IN DD TION T N B Q T H SOt.ASOR CFCOMPENSATION, INTEREST, ATTORNEY'S FEES, AND CAMAGES AS <br />ROVEDFOR <br />I, <br />/ (C•5711venssd suthorizod representotive), hereby <br />authorize_ I <br />'°tip sign this,San.laaquin County Well Permit Applicatlon on my behalf, I understand thls author1r.60on to valld for <br />one (t) year and Is limited to thy work plan dated on tho front page of this applic1110. <br />6-17-2000/MI <br />:"0 +:c_ e0,�,�,; �,_*: EErE59?E0Z E5 �e i 23CZ•/ET/GT <br />12/19/2000 TUE 12:37 iT.X/R] NO 671UI 01002 <br />