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401/11/2'002-TUE 10-:47 FAX <br />11./0.2 TUE 11:20 FAX 1 916 861 0430 SECOR- SACRAMENTO <br />002 <br />LO 00 2 <br />e <br />San Joaquin County Environmental Health Services, Unit IV Well Permit Application Supplement <br />003 0 <br />JOB ADDRESS; 2:Ks."0 .1-21 sts S, Rtl, PERMIT 5R4f:' 0 0'02.-O y <br />yericoi <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 Rusiness and Professions Cade and my license is in full force and effect. <br />Expiration Date: LI/2 403 <br />Date: Joo_z__ Contractor: it Ili 19.L41Z j , <br />Signature: Title: V-(a)dA-ef <br />Printed name: lOLKI F <br />, <br />c .ffe "Ilk/ <br />WORKERS' COMPENSATION DECLARATION <br />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 providod 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 />Carrier: _A6zi" Policy Number: 7/3 -533.V - L/ <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 l <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 /> <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 To ONE HUNDRED THOUSAND DOLLARS <br />(5100,000.), 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 />(signature otC-57 licensed authorized representative), <br />hereby authorize (print name) 13 rstUrN <br />to sign this son Joaquin County Well Permit Application on my behalf. I understand this authorization is valid for <br />one (1) year and Is IlmIted to the work plan dated on the front page of this application. <br />5-17-2000/ Mi <br />License #: C 72-riq 15 Li <br />Care)/