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02/08/2081 14: 23 209e 118 AGE STOCKTON PAGE 03 <br /> San Joaquin County Environmental Health Services, Unit IV Well Permit Application Supplement <br /> JOB ADDRESS:_l Q k PIaRmrr SRIF: <br /> LICENSED CONTRACTORS DECLARATION <br /> I hereby affirm that I am licenced 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#: �p `( � Expiration Date: <br /> Date: n Contractor: <br /> Signature: Title: CYtS <br /> Printed name_ ro <br /> WORKERS' COMPENSATION DECt_ARATTON <br /> I hereby affirm under penalty of pbrjury one of the following declarations: (CHECK ALL THAT APPLY) <br /> I have and wln maintain a cert)ficate of consent to self-Insure for workers'compensation, as provided for by <br /> _._. SS cdon 3700 of the Labor Code,for the performance of the work for which this permit is issued. <br /> ✓71have 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: C ' '� ( XK��t' Policy Number: /i ,5-00 6, <br /> I certify that In the perferrnanca of the work Igor 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 woft",compensation provisions of Section 3700 of the Labor Code, 1 shall <br /> forthwith comply with those provisions. <br /> Date: / �) Signature: <br /> Printed Name; <br /> WARNING:FAILURE TO SECURE WORXERS' COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CML FINE$UP TO ONE HUNDRED THOUSAND DOLLARS <br /> ($100,000.),IN ADDITION TO TME COST OF COMPENSATION,INYPREST,ATTORNEY'S FEES,AND DAMAGLS AS <br /> PROVIDES FOR IN SECTION 3706 OF YHE LABOR CODE. <br /> 1, (C-57 licensed authorized representative),hereby <br /> authoriis li)1 U . <br /> to sign this San Joaquin County Well Pwirnit Application on my behalf. 1 understand this authorization It valid for <br /> one(1)yerr and Is limited to the worts plan,dated on the front page of this applicaraon. <br /> 6-17,2000/MI <br /> e/e 86ed `ZE EL L0-6-gad `•?060 ElE SZ6 : 'oui `buz;sal V bu'TTTJO 669JO :A9 :�uag <br />