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San Joaquin County Environmental Health Services, Unit IV Well Permit Application Supplement <br />,.00302,0,/ <br />JOB ADDRESS; 2.&56i 421 sts S. ..So. Rcli PERMIT SR*:' 0 0 02-0 "f <br />fer6m <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 #: C 7211q 6 4 Expiration Date: 4 /2 403 <br />Date: 1/, ;001— Contractor: <br />Title: <br />Printed name: 2619 d.ezi F ke <br /> <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 sell-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 />Carrier: ._,,ath 4-ago/ Polley Number: 713 -63'_3 1 -_0 <br />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 <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 />($100,000.), IN ADDITION To THE COST OF COMPENSATION, INTEREST, ATTORNEY'S FEES, AND DAMAGES AS <br />PROVIDED FOR IN SECTION 2706 OF THE LABOR CODE. <br />L/4LC— /6-(4•44— (signature otC-57 licensed authorized representative), <br />hereby authorize (print name) Ci rst Cu\ C_AareNii <br />to sign this San Joaquin County Well Permit Application on my behalf. I understand this authorization 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 />Signature' <br />kI 4 "t <br />06/11/2002 TUE 1047 FAX <br /> -211002 <br />06 1 11/02 TUE 11:20 FAX 1 916 861 0430 SECOR-SACRAMENTO <br /> 002