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Sent By : HP LaserJet 3100 ; JetSuite ; 7 - Nov - 01- _, 11 : 51 ; Page 2 / 2 <br /> 11 / 07/ 2001 11 : 12 209466 . _ 3 Page z <br /> FIFTH FLOUR PAGE 02 <br /> San Joaquin County Environmental Health Services, Unit IV Well permit Application Supplement <br /> JOB ADDRESS: S �i em�n '- cp�pERMIT SR#: <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 /> License #: Lf (o (o �L�7 b <br /> Expiration Date: 11 30 <br /> Date: Contractor: _ Tk6e4� Cor�s. 0uvtiA-�- <br /> Signature: Title: n <br /> P 15ZAr� <br /> Printed name. <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the following declarations: (CHECK ALL THAT APPLY) <br /> 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 /> _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: fJi Policy Number:..! ! /_ Ol (ilnyt✓ODODoo <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, 1 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 /> ($1003000.), IN ADDITION TO THE COST OF COMPENSATION, INTEREST, ATTORNEY'S FEES, AND DAMAGES AS <br /> PROVIDED FO SECTION3706 <br /> OF THE LABOR CODE. <br /> it " " • ' " ' !" T _ s�� nature ofC• <br /> �� ( g 57 licensed authorized representative), <br /> hereby authorize (print name) LV <br /> to sign this San Joaquin County Well Permit Application on my behalf. I 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 MI <br />