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P.4 <br />PAGE 02 <br />San Joaquin County Environmental Health Services, Unit IV Well Permit Application Supplement <br />JOB ADDRESS: et AV"- PERMIT SRIt: 61030nY <br />ztio <br />LICENSED CONTRACTORS DECLARATION (LCD) <br />I hereby aMrm 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 A: 4 Ps--(6S-' Expiration Date: //S /02/ <br />Date: <br />Signature: <br />Printed name: CHR/CrotPli/Cdfe PemdvtiR <br />WORKERS' COMPENSATION DECLARATION <br />I hereby affirm under penally of perjury one of the following declarations: (CHECK ALL THAT APPLY) <br />I hint 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 />NNs 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: J <br />Carder: GEM 4?,72,544404vcc, ce/144MIAticy Number: _Cal,LQ22-,-5 ' <br />— I certiTiiihat 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 shell <br />forthWith comply with those provisions. <br />Date: 81/2 0 Signature: <br />Printed Name:ChA <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 ADDMON TO THE COST OF COMPENSATION, INTEREST, ATTORNEY'S FEES, AND DAMAGES AS <br />PROVIDED FOR IN SECTION nos OF THE LABOR CODE. <br />(C-57 licensed authorized representative). hereby <br />authorize <br />to sign this San Joaquin County Will 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 />5-1 7-2000 I kli <br />F:JG 26 2002_ liz.5.1FIN HP LFISERJET 3200 <br />up, Lzr ,cifitoz Ibtug. 4640138 <br />-' • <br />ENVIROMEIATAL I-EALTI-I