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9pr lZ 01 O5: 1ap n .Jones 5-9451 P, Z <br /> 04i12i2001 1-:55 209-57 125 !YJLES-0 ATC J PAGE 02 <br /> San Joaquin County Environmental Health Services,Unit IV Well Permit Application Suppl ment r <br /> .FOB ADDRESS: Z� 1 F n-tc va AVE- PERMIT SR#: ,L9 z <br /> S tcc lLtnn l CCW <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> I hereby affirm that I am licensed under the provisions of Chapter 9 (commencing with Section 7000)of Division <br /> 3 of the Business and Professions Code and my license is in full force ano effect.. <br /> Llcenseti: (aS $(.S- Expiration Date: /I311OZ. <br /> Date: I 0 1I /Contractor, <br /> Signature: kms, ���f Title: C)(>✓^.t e-t' <br /> Printed name: _7.1 VI f SP.t� <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 /> 1 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'compensation insurance <br /> carrier and <br /> policy numbers are: <br /> Cartier.y�`YY 9'T"C' � Policy Number: <br /> _I certify that in the performance of the work for which this permit is issued, I shall not employ any person in <br /> any manner so as t0 become subject to the workers'compensation laws of California,ane agree that if I <br /> should become subject to the workers'compensation provisions of Section 3700 of the Labor Code, 1 shall �4 <br /> forthwith comply with those provisions.- <br /> Date: l a -O I —Signature:nature: � � <br /> Printed Nam a: .�Yl l%6� I- zg_14 <br /> WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> (1100,000.),IN ADDITION TO THE COST OF COMPENSATION,INTEREST,ATTORNEY'S FEES,AND DAMAGES AS <br /> PROVIDED(FOR IN SECTION 3706 OF THE LABOR CODE. <br /> 1, ��t-r0 (C•5711censed authorized mpresentative),hareby <br /> authorize_ A__T(1 <br /> to sign this San Joaquin County Well Permit Application on my behalf. I understand this autharlution is valid for <br /> one(1)year and Is limited to the work pian dated on the front page of this application. <br /> S•17•i000 7 MI <br />