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12/09/2003 TUE 13:21 FAX <br /> 2002 <br /> San,Joaquin County Environmental liealttl Serviced,Unit-W Well Permit.Application Supplement <br /> Jou ADORESS: co PERMIT, SR-W 003(e3 ft <br /> DECLARATION CONTRACTORS DECLAATION ( PJD-) <br /> I hereby affirm that I ant licensed undor the provisions of Chapter 9(commencing wide Section 7000)of Division <br /> 3 of the Business and Pr�o/fe3slon5 Code and my license is in full force and effect_ <br /> Lioense#: ! p "' Expiration Date: T — <br /> Date: onlractAr. <br /> Signature ) Title: L�UGJ <br /> Printed name' _a_— � � ��— <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 /> v/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'componsaWn insurance <br /> carrier and policy numbbeersy.are: <br /> Carver.� Policy Number: L !.-0•' <br /> I certify that in the performance of the work for which this permit is issued,I shalt not employ any person In <br /> any manner so as to become subject to the workers'compensation laws of California,and agree that if 1 <br /> should become subject to the workers'Compensation provisions of Section$700 of the Labor Code, I shall <br /> forthwith <br /> ornply wlth those provisions. i <br /> Date: U Signature:_ <br /> Printed Name: [ <br /> WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT <br /> AN I:MPI-OYER TO CRIMINAL PENAL-TIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> ($100,00.),IN ADDITION TO THF:COST OF COMPENSATION,INTEREST,ATTORNEY'S FEES,AND DAMAGES AS <br /> PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. <br /> 1, (C-57 licensed authorized representativ ), h e V <br /> Authoring Ic <br /> to sign this San Joaquin County Weil Permit plication on my behalf. I understand this authotization is slid fa <br /> one(7)year and is limped to trio work plan dated on the front page of this ap liostion- <br /> wOd� wdt�=ni Eet",i•-vn—�11 <br />