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FROM : West Hazirat FAX 'NO 191663 8613 Nov. 13 2801 02:22PM P2 <br /> lirn��lts►ai ��:nrs teyar 3� FTF H FLOOR � PACE 02 <br /> r <br /> San Joaquin County Environmental Health Services, tilt IV Well PerMit Application Supplement <br /> JOB ADDRESS, <br /> S r PERMIT SR#. <br /> LICENSED CONTRACTORS DECLARATION (LCD <br /> I hereby affirrn that I am licensed under the provisions of Chapi er 3(commencing with Section 7000)of Division <br /> 3 of the Business and Professions Cade and my license is in ft II force anfl effect. <br /> License lf: ^ l " Expirnrion Date. <br /> taow�_�."c � Contractor: r <br /> slgnature .. Title: f <br /> I <br /> Printed name. <br /> WORKERS'COMPENSAT0 DECLARATION <br /> I hereby affirm under penatty of perjury or*of the following des aratiorws: (CHECK ALL THAT APPL'Y') <br /> l have and will maintain a certificate of concent to veff-insu for worketV compensatitan,as provided for by <br /> SUCtiion 3700 of the labor Code, for the performance of the work tar which this permit Is issued, <br /> I have and will maintain workers'compensation i urance,as required by Section 3700 of the Labor Code, <br /> for the peer 0 r9Vwe of the work for which this ptmrrilt is issuerd. My workers'compensation Insurance <br /> carrier and policy numbers are; <br /> C rier-_..... �'QIL+e7 Policy Nu bee;.,_..Z.7.W 43+/6?Z-)q I <br /> ✓ I certify that in the pejrforinarwe of the work for which this rmit is Issue <br /> P c#, I shall not employ any person in <br /> _ any meaner so as to bec cwne3 subject to the workers'comp atkfn laws of Califomia, and agree.jhait if I <br /> should become subject to the workers"Compensation provisions of Section 3700 of th odp,I shall <br /> forthwith comply witt,these provisions, <br /> Date: f / d! Signaturit: <br /> Printod Name: rc,+�i*x _ <br /> WARMNG:FAILURE TO$fECURF WORKERS'COMPENSATR)N CCVCRAGE IS UNLAWFUL,AND SHALL.SUBJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINEs UP TC ONE HUNDRED T14CUSAND DOI-I,ARS <br /> (41 00,D00-1 IN ADOMICN To THE COST OF COMPENSA IUTS U3T,ATTORNEY'S FEES,AND DAMAOFS AS <br /> PROVIDED FOR IN SECTION 3706 OF THE t COD <br /> (signturn MC-37 licensed authorized re <br /> prosettttat5vtf), <br /> her authorho(print name),_. - ^lt d d1� �e-e-S <br /> to mien this 340 Joaquin county Well Pernit Application on my behalf. I understand this aiul;hu za lion Is valit!W <br /> one(1)ya*r and l*limited to the work pian dated on the front pegs r this application. <br /> 5-17-20001 MI <br />