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Apr 12 01 07: 48a n )nes 5-1 11 p• 2 <br /> '767 <br /> San Joaquin Coun Environmental He;klth Services,Unit IV Well Permit Application Supplement <br /> /Y6.5 �o e�� - - oo25Y/S <br /> JO4717 <br /> B ADDRESS: It .&� 94��_ PERMIT SR# .,?14. Ae <br /> /u7 AOA `-AA �/8 <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> (hereby affirm that I am licensed under the provisions of Chapter 9(commencing with Section 700o)of Division <br /> 3 of the Business and Professions Code and my license is in full force an+d effect. �] <br /> License#:_tlOO �n Expiration Date: r- �) <br /> Date: Z'fl l Contractor:_ FLJI-� <br /> SCEi'1�J O V1VV � i - <br /> Signature: Title: C)� J` <br /> Printed name: <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 /> I 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: J Policy Number: —� <br /> _1 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 <br /> should become subject to the workers'compensation provisions of Section 3700 of the Labor Code,l shall <br /> forthwith comply with those provisions. <br /> Date: 4-1 a-0\ Signature: - <br /> Printed Name: V�Ci8 Cil�" <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 /> ($100,000D IN FOR SECTION 37E COST OF T LABOR OFCOMPCODEENSATION,INTEREST,ATTORNEY'S FEES,AND DAMAGES AS <br /> PROVIDE <br /> (C-57 licensed authorized reprosontative),hereby <br /> authorize <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 /> 5-17-20001 Mi <br /> ,, ,T ccncoof.cn7 I z':I G1 TQG17/7.T/bQ <br />