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s 0]X02`02 � WEDS 13:49 FAX1 916,861 0430 SECOR-SACRAMENTO _ 2002 <br /> f 121 002 <br /> a.J <br /> I ' <br /> I <br /> San Joaquin County Environmdattal Health Services,UnIt IV Wetl PeRNt Apq)-:;Va�;gup ' <br /> JOB ADDRESS,-' PERMIT SR#: <br /> Vyt I I <br /> LIC lSED CONTRACTORS DECLARATION (LCD) <br /> I hereby affirm that I am licensed under the provisions of Chapter a(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' t7� <br /> Date: Con ctor. Djaann <br /> Signature- Title: <br /> Printed name; <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm undor penalty of perjury one of the following declarations: (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 /> Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. <br /> Z I 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'compensalion insurance <br /> carrier and policy numbers are, <br /> Carder:UA1'�Lf Policy Number. <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. I shall <br /> forthwith como1ly with those provisions_ <br /> Date: , ZV Signature: <br /> Printod Name: , Vdt_ <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 MUNDRED THOUSAND DOLLARS <br /> ($100,000.),IN ADDITION TO THE COST OF COMPENSATION,INTEREST,ATTORNEY'S FEES,AND DAMAGES AS <br /> PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. <br /> I. ,(CA? ns a onzed representati hereby <br /> authorise ml�al�Jiom -- <br /> to sign this San Joaquin County Well Permit ApplLcatlo n my behtalf- I understand this authorizatl la valid for <br /> one(1)year and Is limited to the work plan dated on the front egE of this apptloation. <br /> Cc., ` `�1 °It�-�}� oa <br /> �,y <br />