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I have and will maintain workers' compensation insurance, as required by section 3700 of the Labor ccOe, <br />for the performance of the work for which this permit is Issued. My workers' compensation insurance <br />earner and oalic nu.nnbere are: <br />Carrier 11-itAid Policy Number: <br />I certify that in the performance of the work for which this permit is issued, I shall riot employ any person in <br />any mariner so as to become subject to trio workers' cornpensation laws of California. arid agree that ff <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: Signature: <br />Printed Name: <br />WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAOE IS UNLAWFUL, AND SHALL SUBJECT <br />AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FIXES UP TO ONE HUNDRED THOuSAND DOLLARS <br />$100,0004, IN AMMON TO THE COST OF C.OMPENSATION, INTEREST, ATTORNEY'S FEES, AND DAMAGES AS <br />PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE <br />E1161)/9 n eli j-,4, (C.57 ncensed euthod2ed representative), hertreY <br />authorize P4 1)a .1--,5oJk) VLLI 4cAtjcec/ C7ee- &viten 4. <br />to sign this San Joaquin County Well Permit Appilcatlon on my behalf. I understand this authorization i valid fot <br />one (1) year arid Is limited to the work plan datod on tha front page of this applcation, <br />5.17.2000 I MI <br />- • <br />4. <br />• <br />San Joaquin County Environmental Health Services. Unit IV Well Permit Application Supplement <br />JOB ADDRESS:A ?e0.---//,-;07-4c_ic:?:z------ PERMIT SR#: e7,Z1Y16. <br />LICENSED CONTRACTORS DECLARATION (LCD) <br />I horoby affirm that am licensed under the provisions Of Chapter 9 (cOMmenCing with Sadler; 7000) of Divislon <br />3 of the Business and Professions Code and my license is in full force and effect. <br />License #: (,t7 Expiration Date: Ca —3 0 — 0 3 <br />Date: - e <br />Signature: <br />Printed name; <br />/14 _CPY, <br /> Title: <br />WORKERS' COMPENSATION DECLARATION <br />I hereby affirm under penelty of penury one of the following declarations: (CHECK ALL THAT APPLY) <br />I <br /> <br />have and will maintain a pertIficate of consent to self-Insure for workers compensation, es provided kir by <br />Section 3700 of the Labor Code, for the performance of tha work fOr which this permit is issued.