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ii• 11/12/99 1r 111 U.60 FAX <br /> V1007J' " b f <br /> rssn -XecremenLu Z�plu <br /> 11-01-?e99 9: 12AM �Q <br /> P. 2 <br /> San JoagtJin County Environmental Health Services,Unit IV Wall Permit Application Supplement 4 <br /> jJOB ADDRESS: PERMIT SR* <br /> I <br /> r LICENSED CONTRACTORS DECLARATION (LCD) <br /> I hereby affirm that I am licensed under the pcgvisions Of Chapter A(cammen.cins with section 7000) of Division <br /> 3 of the Business and,Professions Code and MY license is in full force and//effect_ <br /> License :! a(f9' Expiration Date: `7r/30 OCL <br /> Date: I I /1 q Con r, <br /> Signature <br /> 2Z Title: ` <br /> Printed name: �J f <br /> / 4 <br /> WORKERS' C0NIPENSATIQN DECLARATION <br /> I hereby affirm ulRder pans Ity of perjury one of the following ciecl8rations: (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 /> JSection 3700 of the Labor Code, for the performance of the work for which this permit is issued. <br /> ZI have and will maintain workers'compensation insurance, as required by Section 3700 of the Labor Cotte, <br /> for the performance of the►nark for which this permit is Issued. My workers' compensallon insurance <br /> carrier and policy numbers are: NW <br /> ' r <br /> Czrrier. l� <br /> Policy Numb IY YVC-'�yL4�- <br /> f certify that in the performance of the work for wriich thisermlt is issued I shall not employ ` <br /> p p y an y person in <br /> any manner so as to become subject to the workers' compensation flaws of California, anrs agree v%st if I <br /> should become subject to the workers' compensation provisions of Section 00 of the Labor code, t stall <br /> forthwith comply with those provisions, <br /> Qate: /a9-91 Signature: <br /> Printed Name: <br /> f WARNING, FAILURE To SECURE WORKERS' COMPENSATION COVERAGE IS UN WFUL, AND SHALL SUBJECT <br /> ffff AN EMPLOYER TO CR1MiN^L PENALTIES AND CIVIL FINIS UP TO ONE HUNDRED THOUSAND DOLLARS <br /> I ($100.000_),1N ADDMON TO TWE COST OF COMPENSATION,INTEREST,ATTORNEY'S FEES,AND DAMAGES A5 <br /> !II PROWDED FOR IN SECTIO 09 OF THE LABOR CODE. <br /> IC-S7 licensed autFroriisd representative), hereby <br /> authorise rtfl� �fory 5 SSoci? <br /> to sign this San Joaquin County Well Permit Application on my behalf. I understand this authorization is valid for <br /> one(t)year and is limited to ti-m work plan dated on the front page of this a lication_ <br />