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ORIGINAL <br />San Joaquin County Environmental Health Services, unit IV Well Permit Application Supplement — <br />PERMIT SR#: 2q7.)40--" <br />LICENSED CONTRACTORS DECLARATION (LCD) <br />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 Expiration Date: 0/ -31-63 <br /> <br />Date: 6 4,/- 62 / a I Contractor; jet/L-rS <br />Signature-a2-1 T1t16.1-74-Ta(4,-44-t- <br />Printed name; CH-471-4 L-t-r ca-ire-? <br />WORKERS COMPENSATION DECLARA11ON <br />hereby affirm under penalty of perjury one of the following declarations: (CHECK ALL THAT APPLY) <br />I have and wIfl maintain acertificate of consent to self-insure for workers' compensation, as provided for by <br />Section 3700 of the Labor Code, tor the performance of the work for which this permit is issukid. <br />1,4ave and will maintain workers' compensation insuranda, as required by Section 1700 or the Labor Code, <br />for the performance Of the work for which this pemlit is issued. My workers* compensation insurance <br />carrier and policy numbers are, <br />Carrier: / 11-44,611-1-441--‘ <br /> <br />Policy Number: A//46a4 ffe1/cs---41 0 0 <br /> <br />v'frilfy that in the performance of the work for which this permit is issued, I shall not nniploy any person in <br />any manner so as to become subject to the workers' compensation lawn of California, and agree that it I <br />should become subieci to the workers' compensation provisions of Section 3700 of the Labor Code, I shall <br />forthwith comply with those provisions, <br />Date: y -oz --o signature: <br /> <br />Printed Name: <br />WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT <br />AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP 10 ONE HUNDRED THOUSAND DOLLARS <br />($100,00%), IN AimmoN To THE COST OF COMPENSATION. INTEREST, ATTORNEY'S PUS, AND DAMAGES AS <br />PROVIDED FOR IN SECTION 370a OF THE LABoR CODE. <br />c44-7$11-‘3 )4 1-44/U-rced_/— <br />(C-57 licensed authorized representstive), hereby <br />authorize / Z- / 7z-4-tr cr,,cr <br />to 3ian this San Joaquin County Well Permit Application on my behalf. I understand thi6 authorixation is valid for <br />one (1) year and is limited to the work plan• dated on the front page of this application. <br />5-17-2000t (MI <br />JOB ADDRESS: <br />ct10'