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06/27/2002 THU 12:58 FAX f�002 <br /> San Joaquin County Environmental Health Services,tlnitJV Well Permit application Supplement <br /> z <br /> JOB ADDRESS' Jill PERMIT SC3;'#: 3036 <br /> _ za 0 -S 3► <br /> ILIDI W - 1�-e-rxUv%t• S <br /> LICENS D (L <br /> Cb44ACTCRS DECLARATION CD) 306 I <br /> I hereby affirm that I am licensed under the provisions of Chapter g (comrr)errcirjcd witli Section 7000)of Division <br /> 3 of the Business and Profession* Code and my license is in full force and effect. <br /> License#: l o qQ"7 Expiration Date: �1 , <br /> Date:_ jontractvr_ �l_ y'j.lr Illl�C� C — - <br /> signature: • �f 7 Title' <br /> Printed name: ` 0 A- - <br /> / WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury ono of the fallowing 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 /> ✓ I have and will mwntain workers'compensation irrsurance, as required by Se tion 3700 of the Labor Code, <br /> .__for the portormance of the work for which this permit is issued. My workers' compensation insurance <br /> carhor and policy numbers are: { l <br /> Carrier C 1 l.tl I _ _Policy Number- 5 <br /> I certify that in the performance of the work for which this permit is issued, I shalt not employ any person in <br /> any me»ner so as to become subject to the workers'compensation laws of California, and agree that if I <br /> shoulo become suri)ect to the workers'compensation provisions of Slstion 3700 of the Labor Code, I shall <br /> forthwith comply with those provisions. <br /> Date". 1 Signature: . �• — <br /> Printed Name: <br /> WARNING'FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT <br /> AN r:MPLOYER TO CRIMINAL PENALTIES AND CIVIL PINES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> (S?D0,000.),IN ADDITION TO'FHE COST OF COMPENSATION, INTEREST,ATTORNEY'S FEES,AND DAMAGES AS <br /> PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. <br /> J <br /> l (C-57 iieensed authorized representative), hcroby <br /> autttiorizo ""� <br /> to sign thin San Joaquin County Well Permit Application on my Dehalf. t understand this authoT'ziatlon i;valid for <br /> ane(1)year and is limited to the work plan dated on the front158,96 of this application-_ <br />