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04/30/2004 FRI 13:03 FAX Z o03 <br /> San soaquin County Erlvironrnental Health Sorvicet;,UnIt.IV Weil Permit�.pplioation Suppterneoit <br /> Z3 1 S N . (EA D X-���(6) S->< PERMIT Sk#: <br /> JOB ADDRESS , <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> hereby affirm that I am licensed under the provisions of Chapter 0 (commencing with Section 7000)of Division <br /> 3 of the Business and Professions code and my license is in full force and effect, <br /> 7 n <br /> license# Expiration Date: <br /> __ I c�0�a , r — _ <br /> S, 7 - ontractor-�f 'C <br /> Date:-- — <br /> - � ��JL <br /> Title, n 1AJIJ .— <br /> Signature: <br /> Printed name: <br /> WORKERS' COMPENSATION DECLARATfON <br /> hereby affirm under penalty of perjury one of the following declarations: (CHECK ALL THAT APPLY) <br /> I have and will maintain 2 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 isissued. <br /> I have and will maintain workers'compensation insurance, as required by Section 3700 of the Lobor 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 /> Polley Number: <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 it) <br /> should become subject to the workers'compensation provisions of S94tion 3700 of the Labor Lode, 1 shall <br /> forthwith comply with those provisions, <br /> Signature,. 'ru <br /> Date: <br /> J— `!/ <br /> PROVIDED OFA Printed Name: �- 1� ��' <br /> WARNING:FAILURE TO SECURE WORKERS'COMPENSATION L <br /> COVERAGE IS UNt-AWFULAND SHALL SUBJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> P ) ISECTION 37 6 O HE LAi3Q CODE,DIT)ON TO THE COST OF <br /> ATION INTEREST,ATTORNEY'S FEES,Aa PID DAMAGES AS <br /> — —(C n <br /> -57 licesed authorized representative), hereby <br /> 1, <br /> aurhorize cZ 10 <br /> to sign this San Joaquin Cvanty Well Permit Application on my behalf. 1 understand this authorization is valid for <br /> one 11 anlimited to the work plan dated an the front page of this application. <br /> .�..edr d is <br />