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JAN-15-03 WED 01 :31 PM ENPROD 9165892230 P_ 02 <br /> • • <br /> 01%15/2003 12:54 FAX 209 9480621 <br /> � �J902 <br /> San Joaquin County Environmen{al Health pepartment Unit Iv Well permit—Application Supplement <br /> pplement <br /> JOB ADDRESS: ��� PERMIT SR#:_ <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> I hereby affirm that I am licensed under the provisions Of Chapter 8 (commencing with Section 7000) of Division <br /> 3 Of the Business a7ndZProfesssions Code and my license is in full force and effect. <br /> license*: 7" T O v ��� <br /> Expiration Uate; <br /> bate C ntractor: _ _.--- - <br /> Signature: _ <br /> Title: - <br /> Printed name: <br /> WORKERS' COMPENSATION DECLARATION <br /> iI hereby affirm under penalty of perjury One of the following declarations: (CHECK ONE) <br /> I have and will maintain a certificate of consent to self-insure for workers' compensation, as provided for <br /> by Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. <br /> XI have and will maintain workers' compensation insurance, as required by Section 3700 of the <br /> I for the performance of the work for which this permit is issued. My workers' com ens Labor Code, <br /> carrier and policy numbers are: p ation insurance <br /> Carrier: T� �y '7.� <br /> Policy NumbBr:_.// �.�/-__..--3 6'� <br /> .— <br /> I certify that in the performance of the work for which this permit is issued, I shall no — <br /> any manner so as to be not to <br /> come subject to the workers' compensation laws of Californla, and agree that on in <br /> should become subject to the workers' compen sati9n visions of Section 3700 of the Labor Code, I if I <br /> shall <br /> forthwith Cbrrlply wii those provisions, <br /> Data: --zt-��/ - <br /> Printed Name: r <br /> ------ _ <br /> WARNING: FAILURE TO SECURE WORKERS' COMPENSA <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINETION cS UP TO VERAGE IS UNLAWFUL, AND SHALL SUBJECT i <br /> I <br /> (5100,000J, IN ADDITION To THE G03T OF COMPENN, INTEREST, ATTORNEY'S O 'ONE HUNDRED THOUSAND <br /> SATIOAND DAMAGES q5 <br /> PROVIDED FOR IN SECTION 3706 OF THE LA13OR CODE. <br /> A ORI TIO FOR gTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> (Signature OFC-57 licensed authorizes re r <br /> hereby authorize (print f c P Qs entatlVe), <br /> (p nt na»Ie)� , <br /> to sign <br /> this San Joaquin Count <br /> Y <br /> one(1)year and Well Permit Application on my behalf, I understand this authorization is valid for <br /> iS limited to the work Plan dated on the front page of this application. <br /> 5-29-tl2/MI <br />