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Apr 12 01 07: 48a n ^>nes S it p• 2 <br /> D/U F o�i7L� �2 <br /> San Joaquin Coup Environmental a Ith Servlces,Unit IV Well Permit Application Supplement <br /> /Y6.15 Lw n9 �iR4 <br /> JOB ADDRESS: t�Eo� a PERMIT SR# <br /> iZ&7 A0AC 171 <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 Code and my license is in full force and effect. <br /> License#: Expiration Date: <br /> Date: LL L Z--0 k Contract/or:_ F s, A En-\)i, Q to"-CVN1 <br /> Signature: �t ```>�l Title: <br /> Printed name: �S <br /> WORKERS' COMPENSATION DECLARATION <br /> 1 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 /> ✓ 1 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 /> J D65-0)-0 <br /> - �carrier: <br /> _I certify that in the performance of the work for which this permit is issued,t 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 with those provisions.`'t' <br /> Date: -) �-'�� Signature: k { <br /> Printed Name: Vi <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 /> (5100,000.),IN ADDITION TO THE COST OF COMPENSATION,INTEREST,ATTORNEY'S FEES,AND DAMAGES AS <br /> PROVIDED FOR IN SECTION 337706 OF THE LABOR CODE. <br /> (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 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 /> .. cchcoof.cn� 1c,_10 TCIC17/7T/bQ <br />