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,05/15/2000 08:21 209468 FIFTH FLOOR 0 PAGE 03 <br /> F <br /> nvirnnmental HealtkServices„Unit IVtAfetl PemfltAppltcalolbplemerlt <br /> I rat'•{ICENSED CONTRACTORS DECLARATION (LCD) <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 and Professions Code and my license is in full force andO <br /> Expifation Date: <br /> License <br /> Date: _Contractor: 1 <br /> Title: r !87�0/1 f �OILP�e� <br /> Signature: Y� <br /> Printed name: r <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the following declarations: (CHECK ALL THAT APPLY) <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 /> I have and will maintain workers' compensation insurance,as required MY by Section <br /> 3700 <br /> of nthe nsu anon ode, <br /> for the performance of the work for which this permit <br /> carrier and policy,.numbers are: <br /> Policy Number: G OBZ — <br /> Carrier: �oS!s'r' ., �„ person in <br /> that in the perforrilnce of the vrork for which this permit is issued, I shall not employ any p <br /> I certify ect w the workers' compensation laws of California, and agree that if 1 <br /> any manner so as to becom29sitbj <br /> should bbRome subject to the workers' compensation provisions of Section 3700 of the Labor Code, I shall <br /> forthwith cgmply with those provisions. <br /> Signature: <br /> " Printed Name: <br /> +. <br /> AN EMP OYER u CRIMINAL PENAOL7ES AND C VIIL FINE$ P TO ONE HUNDRED THOUSAND DOLLARS <br /> KERS' COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL UBJEC <br /> ($106,000.), IN ADDITION TO THE COS'Tl OF COMPENSATION,INTEREST,ATTORNEY'S FEES,AND DAMAGES AS I <br /> PROVIDED FOR IN SECTION {OR <br /> ��/"j✓JJ _(C-57 licensed authorized representative), hereby <br /> authorize <br /> to sign this San Joaquin County Well Permit Application on my behalf, i understand this authorization is valid or <br /> one(1)y <br /> ear and is limited to the work plan dated on the front page of this ap lication. <br />