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01/1112002 14: 58 20946634` FIFTH FLOOR PAGE 05 <br /> ltw %ftw <br /> San Joaquin County Environmental Health Services,�Unit IV Well Permit Application Supplement <br /> JOB ADDRESS: VA") We-5k- Pemon� AVB PERMIT SR#: 3 O <br /> 5ko r-14o%n*CA <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 and effect. <br /> r. <br /> License#: c.(05SS� Expiration Date: 11 - -O 3 <br /> Date: 7— �41 d —Contractor. PC Et I! rf (G ` <br /> Signature: Title: Dy !!l Yl a <br /> —T. - - <br /> Printed name: t°i FMO/ Ina <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 /> XI 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: � �9/577,2 <br /> Carrier: ,de D �w-anca Policy Number: U� <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 to become subject to the workers,' compensation laws of California, and agree that if I <br /> should become subject to the workers' compensation provisions of Section 3700 of the Labor Code, I shall <br /> forthwith comply with those provisions, <br /> Date: Signature'. <br /> Printed Name: <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 /> 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 /> I, / Flem ofC-57 licensed authorized representative), <br /> hereby authorize(print name} .son✓le !em <br /> to sign this San Joaquin County Wall Permit Application on my behalf. 1 understand this authorization is valid for <br /> one(1)year and is limited to the work plan dated on the front page of this application- <br /> 5-17-2000 I M I <br />