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r + 2-10-2000 11 :25AM FROM P• 2 • Y i� San:Joaquin County-Environmental:Health Services,Unit IV,Well f?ermit•Application:Supplement JOB ADDRESS: 449 ' �`�- PERMIT SR#: LICENSED CONTRACTORS DECLARATION (LCD) I hereby affirm that I am licensed under the provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code and my license is in full force and effect License#: G 7 ' Si�10 Expiration Date: Date: y C ntra or. -e�-- i Signature: Title: 1.f Printe ame: ✓ Ad- WORKERS' COMPENSATION DECLARATION I hereby affirm under penalty of perjury one of the following declarations: (CHECK ALL THAT APPLY) _I have and will maintain a certificate of consent to self-insure for workers'compensation, as provided for by Section 3700 of the Labor Cede,for the performance of the work for which this permit is issued. I have and will maintain workers'compensation insurance, as required by Section 3700 of the Labor Code, `for the performance of the work for which this permit is issued. My workers'compensation insurance carrier and policy numbers ars: Carrier: Policy Number: .W G Z 5 tq Zg c7 certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to become subject to the workers'compensation laws of Califomia, and agree that if I should become subject to the workers'compensatio r visi;76700 Labor Code, I shall forthwith comply with those provisions. Date: Lr�01 Signature: Printed Name Ac klf Gr WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS ($900,000.),IN ADDITION TO THE COST OF COMPENSATION,INTEREST,ATTORNEY'S FEES,AND DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. I, (C-57 licensed authorized representative),hereby authorize to sign this San Joaquin County Well Permit Application on my behalf. I understand this authorization is valid for one 9 year and is limited to the work Ian dated on the front page of this application.