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10/27/2003 11:12 209468343 FIFTH FLOOR PAGE oz <br /> - <br /> go <br /> San Joaquin County Environmental Health Department Unit IV Well Permit Application Supplement <br /> JOB ADDRESS-. <br /> i1°5o✓1 ��r7l��al PERMIT SR#: <br /> Train J (4 <br /> LICENSED 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 Codeand my license is in full force and effect. <br /> License#: C—S / —_)/00_7l Expiration,D(ata:—Ay <br /> Contractor, <br /> Date: <br /> r. <br /> Title: �°�•,� � �- l�/I¢,a.e <br /> s- <br /> Signature* <br /> Printed name: //i9S"4": <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the following declarations: (CHECK ALL THAT APPLY) <br /> _I 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 /> as required by Section of theLabor Code, <br /> I have and will maintain workers'compensation insurance, compensation insurance <br /> for the performance of the work for which this permit is issued. My workers' compensa <br /> carrier and policy numbers are: Oh C <br /> policy Number: R <br /> Carrier: _ J <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 California,and agree that if I <br /> should become subject to the workers'compensation provisions of Section 3700 of the Labor Code, I shall <br /> forthwith comply <br /> �with <br /> (those provisions- <br /> Date: � 1) Signature: ` <br /> Printed Name: <br /> �✓Y�y;fi� \ r Cwt 1tAP\� <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 /> ($100,000COMPENSATION,INTEREST,ATTORNEY'S FEES,AND DAMAGES AS <br /> PROVIDEDOR IN SECTION 3706 OF THE LABOR <br /> i `4� \ 'K� (signature ofL-57 licensed authorized representative), <br /> hereby authorize(print name) <br /> to sign this San Joaquin County Well Permit Application on my behalf. I understand this authorization is valid for <br /> one(1)year and is limited to the work plan dated on the front page of this application. <br /> 1-25-021 MI <br />