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09/28/2004 TUE 06:19 FAX 1@002 <br /> 12/2612Af1:; 08: 3� 3)GiiL,lr-4'4n � :,E-r-:1-��� <br /> • ':;fad P12/03 <br /> San Joaquin County Environmental Hcalth Department Unit IV Well Permit APP[jaation Supplement <br /> JOB ADDRESS: a (oS iJ�nf1�� PERiMIT SR#: <br /> LICENSED CONTRACTORS DECLARATION (LCI) <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 ono Profes7i ns Code and my license is In full form and ffecL , <br /> License#; 1 '�cp' t'in o:�to: �'"l V <br /> �` ' 1 f <br /> Datil: S Z S U -_Contra t4� :��.j ,,a,Jr <br /> Signature; (-,;7 Title: <br /> Prinked n2lme: <br /> WORKERS' CON(PENSATI DECLARATION <br /> I hereby affirm under penalty of perjury one of the following declarations: (CHECK ONE) <br /> i have and will maintain a certificate of consent to self-insure for workers'compensation, as provided for <br /> by Section 3700 of the Labor Code, for the performance of the work for which this hermit 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 tha work for which this permit Is issued. My workers'compensation insurAnce <br /> carrier an policy numbe s are: <br /> Carrier• � � C .Paitcy Numhc:r: <br /> I certify that in the performance of the worts for which this permit is issued.I shall not employ any person in <br /> any manner so as to became subject to the workers'compensation laws of California,and agree that if I <br /> should become subject to the workers'cornpensa ion provisions of Section 3700 of the Labor Code, t shall <br /> forthwith comply with those provisions. <br /> Date: Signature' <br /> Printer) Name: <br /> WARNING,FAiLURE TO SECURE WORKERS'COMPENSATION COVERAGE iS UNLAWFUL_, >1 SHAD SUBJECT <br /> AN CMPLOYER TO CRIMINAL PENALTIES AND CIViL FIRES UP TO ON1=HUNDRED THOUSAND DOLLARS <br /> (g100,Opo,f,IN ADDiTiON TO THE COST OF COMPENSATION,INTEREST,ATTORNEY'S FEES,ANO DAMAGES AS <br /> PROVIDED FOR iN SECTION 37OG OF TKE LABOR CODE. <br /> THORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> 1, �c .� ,_,,,(signature oto-57 licensed authorized represontutive), <br /> r <br /> hereby authorize (Print name) , <br /> tv sign this Son Jaaquln County Wall Permit Application on my beharf. I understand this authorization is valid for <br /> ` one(1)year and Is limited to th"work plan riatead on the front page of thio APpilcation. <br /> Q-29-021 MI <br /> t2i26/2003 FIZI OK=26 ITl/RX NQ 92221 2100 ' <br />