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Apr 12 01 05: 1Op n Jones 5-9-451 p. 2 <br /> 04/12/21101 17:55 209-3,,..,225 HDDESTO ATC `J PAGE 02 <br /> San Jeaquln County Environmental Health Services,Unit IV Well Permit Application SupplMnent <br /> 14 2 <br /> JOB ADDRESS: Fonto na. Ave- PERMIT SR#: <br /> 15"c ftA i C.W <br /> LICENSED CONTRACTORS DECLARATION LCD <br /> 1 hereby affirm that 1 em 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 fun force and effect. <br /> License!(: Expiration Dale: 1 3102 <br /> Date: '4-1 Z) 0 1� —Contrractor:- F scyk <br /> _�cC <br /> Signature: L�'�f Title: 60--'1 oar <br /> Printed name- .L)GVI A C� <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 policy'numbers are: <br /> Carrier: a--e ('> Policy Number: 115 3 to DO 5 _6 I <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 s0 a5 to become subject to the workers'compensation laws of California,and agree that if I i <br /> should become subject to the workers'compensation provisions of Section 3700 of the Labor Code.1 shalt <br /> forthwith comply with those provisions. <br /> Date: -12 -O I Signature:_ /"` <br /> Printed Name: Yl G-%6� )Q e,/4 <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 /> ($100.000.),IN ADDITION TO THE COST OF COMPENSATION,INTEREST,ATTORNEY'S FEES,AND DAMAGES AS <br /> PROVIDEDFOR IN SECTION 37860E THE LABOR CODE. <br /> ; <br /> 1, �L/L,/1�VI� �1Jn.(-i (C-57 licensed authorized representative),hereby <br /> authorize /7-70 _ <br /> to sign this San Joaquin County Well Permit Application on my behalf. I understand this authodzaDon is valid for <br /> one(1)year and Is limited to the work plan dated on the front page of this applkeation. <br /> 5.17.2080!MI <br />