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10/18/2081 15:07 20-� 71118 AGE 5TOCKTOh PAGE 07 <br /> San Joaquin County Environmental Health Services, unit IV Well PermitI lett Vs Wn , <br /> JOB ADDRESS:-,L ' PERMIT SR#: <br /> LICENSED CONTRACTORS DECLARATIONL( CD? <br /> I hereby affirm that I am licensed under the provisions of Chapter 9 (commencing with Section 7000)of Division <br /> 3 of the Suuiness and Professions Cods and my license Is In full force and effect. <br /> License#: GS 7 (eC�(, 4 t1? Expiration Date: ni t4213 <br /> Date: Contr ctor 6� r r►-� 1, � �+C - <br /> Signature: `V Title: <br /> Printed name: <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm under penalty of pedury one of the following declarations: (CHECK ALL THAT APPLY) <br /> I have and will maintain a certificate of consent to self-insure for workam'comp©nsetion, as provided for by <br /> Section 3700 of the Labor Code,for the performance of the work for which this permit Is issued. <br /> X1 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: milCt ,& ' rkjnr Policy Number: <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 Caiifomia, and agree that K I <br /> should become subject to the workers'compensation provisions of Section 3700 of the Labor Code, I shalt <br /> forthwith comply with those provisions. — 11102 <br /> Date: /D//9/p! "tpl, -- <br /> Signature: <br /> Printed Name: aidLn&s4ar <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 /> ($100,400.),IN ADOMON TO THE COST OF COMPENSATION,INTEREST,ATTORNEY 3 FEES,AND DAMAGES A3 <br /> PROVIDED FOR IN SECTION 3709 OF THE LABOR CODE. <br /> 1, I�i ' e/ �r,(�0 le (C-ST licensed authorized repreaentative),hereby <br /> authortt <br /> to sign this San Joaquin County Well Permit Applleatlon on my behalf. I understand this authorization Is val)d for <br /> orte(1)year and is limited to the work plan dated on the front papa of this application- <br /> 5-17-2000 f MI <br /> b/C 06ed `•SO:0G 10-61-130 `eoeo Cl.e 976 `• 'cuI `but;sal � 6UTITtup 669uE :49 luas <br />