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Carrier: Fold Policy Number: 1/ 5334-cn <br />0( Signature: <br />Jczil (.TV <br />Sari•joaqUin.CpUnty'EnvirOn'thental Health erVieee:,.1.1riltIV Wei I.ferrnit ApriWeetion ,Sup'Plement <br />. PERMIT.7SR#: ? ea 2—, <br />&RS— <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 #: 7009r)14 Expiration Date: 4/340;?:s <br />Date: , Con actor; Vim' ti-)/7tioj <br />Title: <br />Printed name: <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-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 />I have 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 />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 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 <br />forthwith comply with those provisions. <br />Printed Name: JIM/ Vid,-,,epLi <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 />01 <br />Signature: <br />JOB ADDRESS: <br />a . 7I'L ,e-Jelyt) <br />to sign this San Joaquin County Well Permit Application on my behalf. I understand this authorization is valid for <br />one () year and is limited to the work plan dated on the front page of this application. <br />Date: 1211 <br />(C-57 iicens ii0drizced :Presentative), hereby <br />Vi ix& <br />Di <br />authorize <br />t ' <br />1 12/06/2001 THU 14:11 FAX <br />n W40 <br />!002