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10/18/2001 15:07 209• -110 AGE STOCKTON PAGE 05 <br /> San Joaquin County Environmental Health Services, Unit IV Well Permit Application Supplement <br /> JOB ADDRE83- 3oZ i - Cpf ` 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 affect. <br /> License#: fS7 G5(o 14ar7 Explratlon Date: at <br /> Date: I I Contractor: ('q, �M S <br /> Signature: Title: ��r <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 /> 1 have and will maintain a certificate of consent to self-Insure for workers'compensation, as provided for by <br /> /Section 3700 of the Labor Cede,for the performance of the work for which this permit is issued. <br /> Y 1 have and will maintain workers'Compensation Insurance, as required by Section 3700 of the Labor Code, <br /> T for the performance of the work for which this permit is issued. My workers' compensation insurance <br /> - <br /> carrier and policy numbers are: <br /> Carrier: Marc& C &�__Policy Number: We 2V `D Cs.-S-_i6_0 _- <br /> I certify that In the performance of the work for which this permit Is issued, 1 shall not employ any person In <br /> any manner so as to become subject to the workers' compensation taws of California, and agree that rf I <br /> should become subject to the workers' compensatlon provisions of Section 3700 of the Labor Code, 1 Shall <br /> forthwith Comply with those provisions. <br /> Date: /Clif eJ� / 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 /> ($100,000.),IN ADDITION TO THE COST OF COMPENSATION,INTEREST,ATTORNEY'S FFrs,AND DAMAGES AS <br /> PROVIDED FOR IN SCCTION 9706 OP THE LABOR CODE. <br /> I•- �...��^�L),�- (C-67 Ilcenaed euthoriied representative),hereby <br /> authorize <br /> to sign thle San Joaquin County Well Permit Application on my behalf. i understand this authorization ie valid for <br /> ono(1)year and is limited to the work plan dated on the front page of this application. <br /> s-17-2000/MI <br /> q/Z abed !90:01 10-61-;oo `eOUG CIC Se6 `- 'ouI `0ui}sal y butTTTuO 660u0 :!g }uaS <br />