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r C-071 11-,3 A <br />(C-57 licensed authorized representative), hereby <br />74— LSZ/Tail <br />e)it-C- 67A-) 'A /Là XI Pt C?"'S 4.J A3 authori <br />%;*Elli4zijo, FAX NO. : 19166388613 Sep. 18 2r _ 09:58AN P2 <br />San -loaquip countyEnvirphmntai Health sorvIces, Unit IV Well Permit Application -Supplement <br />JOB •AblpiRE;$ ;at/4 24*C=1/5 / C 40-r- , PERMIT SR#:_40 <br />H. 190" 5_ <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 4: -1 '7 <br />Date: 0 F- ie-0 I Contractor: <br />Signatif; 6?, <br />Printed naryr6: cal-A-fi-vJ A 4e,.$)14,r <br />Expiration Date: c5) / - 3/ 0 3 <br />r C6 i <br />7 <br />TIc fe)44' <br />WORKERS' COMPENSATION DECLARATION <br />I 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-inalire 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 />Zihave 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 carrier and policy numbers are: <br />Ca cri or: 2-44--7-/-q5/1-4A Policy Number: 2 2- t" 17 2. 7 <br />I certify that In the performance of tho 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 the Labor Code, I shall forthwith comply with those provisions. <br />Date: 0 '7 -/&'.0 Signaturte--- I <br />Printed Name: "1- 717..7'.1 4 <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 />($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 />to sign this San Joaquin County Well Permit Application On my behalf. I understand this authotizatIon Is valid for <br />one (1) year and Is limited to the work plan dated on the front page of this application. <br />5-17-2000 / MI <br />el00-1_1 HIAld EEPES9P68Z PS:LO 000Z/GZ/01 t)0 7J9Vd