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002 12/09/2003 TUE 13:21 FAX <br />San Joaquin CoU'rity E.nvironinental Health Services:, Unit IV Well Permit <br />:Application Supplement <br />JOB ADDRESS: Ce3 PRIOT SR#:.003t03 (61 <br />LICENSED CONTRACTORS DECLARATION (LCD) <br />/ hereby affirm that I arn 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 />a <br />License #: /190 611 <br />Expiration Date <br />/L. <br />Title: <br />Date- \a <br />SignatUre: <br />Printed name: <br />WORKERS' COMPENSATION DrCLARATION <br />I hereby affirm under penalty of perjury one of the following declarations: (CHECK ALL THAT APPLY) <br />have and will maintain a certificte of con:sent to self-insure to workers compensation, as provided for by <br />Section 3700 of the 1_21por Code. for the performance of the work for which this permit Is issued. <br />I have and will maintain workers' compensation insurance, as required by Section 3700 <br />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 />Policy Number: <br />Carrier: <br />__ 1 certify that in the performance of the work for intlict) this permit is issued, <br />1 shalt not employ any person In <br />any manner so as to become subject to tne workers' compensation laws of California, and agree that if I <br />should become subject to the workers' compensation provisions of Sedion 3700 of the Labor Code, I shall <br />forthwith oMp with those provisions- <br />Date: D <br />< 7 <br />_...--" <br />. . . _ 1 Slgnature: ___ <br /> <br />Printed Name: 6 ' \fl derlil'I----- <br />PROViDED FOR IN SECTION 3706 OF -rHE LABOR CODE. <br />IA <br />I, <br />(C-57 licensed authorized represcntativ ), h <br />/ lhallted7 111' / <br />authorize <br />- I' to sign this San Joaquin County Well Permit • splication on my behalf. I understand this authorization is sild for <br />one (1) year and is limited to ths work plan dated on the front page of this application_ <br />Nvr_c3,21 <br />WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT <br />., <br />AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br />($100,D043.), IN ADDITION TO THE COST OF COMPENSATION, INTEREST, ATTORNEY'S FEES, AND DAMAGES AS <br />ta