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Jun 11 04 04: 00p Ma, Walden 925" -35715 p . 2 <br /> 4&4 - bl 3Y <br /> San Joaquin County Environmental Health Services, Unit IV Well Permit ApplicationS�-3 <br /> JOB ADDRESS: 29M rtsr +-A PERMIT SR#: 603 <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#:_ �/ Expiration Date: <br /> Date: Contractor: r e <br /> Signature: /` Title:U�6- g <br /> Printed name <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm udder penalty of perjury one of the following declarations: (CHECK ALL THAT APPLY) <br /> I have andJ�II 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 l maintain workers'compensation insurance, as required by Section 3700 of the Labor Code, <br /> 0 twhe performance of the work for which this permit is issued- My workers'compensation insurance <br /> carrier and policy numbers are: <br /> Carrier: __Policy Number: ZAu) j Q� �7 <br /> 14 1 certify thatll the performance of the work for which this permit is issued, I shall not employ any person in <br /> any manneas to become subject to the workers' compensation laws of California, and agree that if I <br /> should becosubject to the workers' compensation rovisions of Section 3700 f the Labor Code, I shall <br /> y with those provisions. <br /> Date: �Q �' r • Signature: <br /> Printed Name:_ c.L� <br /> WARNING: FAILU�{!E TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT <br /> AN EMPLOYER TCS CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> ($100,000.), IN AD ITION TO THE COST OF COMPENSATION, INTEREST, ATTORNEY'S FEES,AND DAMAGES AS <br /> PROVIDED FOR INISECTIO/N3700660OF THE LABOR CODE. <br /> I• ✓`�`^� C (signature ofC-57licensed authorized representative), <br /> hereby authorize( hint name) Ae'y o <br /> to sign this San Joiquin County Weft 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 /> 5-17-20001 MI <br />