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03/21/2003 FRI 13:48 FAX 0003 <br /> Enwirottimental lie�lth S,Brvices.Unit�iv We11 PermitApplica.tion Su,p.plement <br /> San Joaquin county r <br /> PERMIT SES#" <br /> F-JJOB ADE�RESS:�J�� � • �� — <br /> CLARAT1ah! LCD) <br /> LICENSED CONTRACTORS 17E t <br /> hereby affirm that I am licensed under the provisions of Chapter 8 (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# 451/ <br /> � Expiration Date. <br /> er_Date: ontractor_ Title:SignaturePrinted name: —�Jo - J h f <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the following declarations: (CHECK ALL THAT APPLY) <br /> 1 have and will maintain a certificate of consent to self-insiure 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 tabor Gode, <br /> T for the performance of the work for which this permit is issued. My workers' compensation insurance <br /> carrier and policy numbers are; <br /> Policy Number:., <br /> Carrier:—bta <br /> I certify that in the performance of the work for which this permit is issued, I shali not employ any person In <br /> any manner so as to became subject to the workers' <br /> n ation provisions of S asaltion Ion 3700 ofof �the Laba, and w Code, I ree diat Ishall <br /> should become subject to the workers'comf J <br /> ae <br /> forthwit co ply vAh those provisions. <br /> Date: <br /> Printed Namo: <br /> WARNING: FAILURE TO SECURE WORKERS, COMPENSATION COVERAGE 1S UNLAWFUL,AND SHALL SUBJECT <br /> AN 1 MPLOYER TO GRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> ($100,DDQ.), Ih1 ADDITION TO THE COST OF COMPENSATION,INTEREST,ATTORNEY'S TEES,AND DAMAGES AS <br /> PROVIDE' FOR IN SECTION 3706 OF THE LABO12 CODE- <br /> (C-57 licensedlauthorized representative), heretry <br /> authorize �y <br /> Application on m behalf. I understand this authorization is valid fo <br /> to sign this Sem Joaquin County Well P�armi{ r <br /> one(1 year and IS limited to the work plan dated on the front age of this application. __ <br />