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Cc_Lc4 <br />(2-0 co <br />1.2=C43-2_o l 222 <br />JOB ADDRESS: 2- 0 Rot-e_avv 94 PERMIT SR#: <br />tcl (tit( e ta <br />LICENSED <br />- <br />LICENSED CONTRACTORS DECLARATION (L(D) <br />I hereby affirm that I am licensed under the provisions of Chapter 9 (commencing with Section 7000) of Division <br />License #: Expiration Date: / 0/ <br />Date: /I/ / Contractor. <br />Signature: <br />L0a <br />WORKERS' COMPENSATION DECLARATION <br />I hereby affirm under penalty of perjury one of the following declarations: <br />(CHECK ALL THAT APPLY) <br />I <br />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 />have and will maintain workers' compensation insurance, as required by Section 37130 of the Labor Code, <br />r the performance of the work for which this permit is issued. My workers' compenisation insurance <br />carrier and policy numbers are: <br />7-71-boOf 0,277 <br />Carrier <br />Signature: <br />Printed Name: <br />, <br />(signature ofC-57 licensed authorized representative), <br />hereby authorize ( rint name) <br /> <br />to sign this San Joaquin County Well Permit Application on my behalf. I understand this <br />, thorization 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 I MI <br /> <br />uapien RJew d65:60 O TI use T esas <br /> <br />San Joaquin County Environmental Health Services, Unit IV Well Permit Applica ion Sup <br />A03 22_ <br />3 of the Business and Professions Code and my license is in full force and effect. <br />re -7J- <br />6-),=, Title: <br />Printed name: <br />Date: <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 THOU AND DOLLARS <br />($100,000.), IN ADDITION TO THE COST OF COMPENSATION, INTEREST, ATTORNEY'S FEt <br />, S, AND DAMAGES AS <br />PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. <br />(cr1) <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 Californi4, and agree that if I <br />should become subject to the workers' compensa on rovisions of Section 3700 sI the Labor Code, I shall <br />forthwith comply with those provisions. <br />Policy Number.