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San Joaquin County Environmental Health Services, Unit IV Well Permit Application Supplement <br /> JOB ADDRESS: 6�D?� f l SLY C(ti� PERMIT SR#: D4zFd4 ,3 <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> I <br /> hereby affirm that 1 am licensed under the provisions of Chapter 9(commencing with Section 7000)of Division <br /> 3 of the Business and Piofessrons Code and my license is in full force and effect. <br /> License#. L0— 1 �W-G / ExplreEen Date: ` —/3]0—02 <br /> Data: 1 —5--01 <br /> -0 1 CConttrrra�ctor: L S GALL/�/� 5n�/'�/ 1 a2 <br /> Signaturv:, AI AI-D 1 Title:_ / S- <br /> Printed name: W v,t�+i Tko/t'+,�5 f/JN_ <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm under 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 1 <br /> Section 3700 of the Labor Coda,for the performance of the work for which this permit is issued. <br /> I have and witl 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' compensation insurance <br /> carrier and <br /> 'policy numbers are: <br /> Cartier:_� -07,- -�jpo"AT7Grv.TAJS.l-policy Numbor. WC <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 agnea that if I <br /> should become subject to the workers' compensation provisions of Section 3700 of the Labor Code,1 shall <br /> forthwith comply with those provisions. <br /> Date:. L-15--o r Signature: <br /> Printed Name: WA<4 TN2NIlose"' <br /> WARNING: FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CML FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> (f100,000.),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 /> / <br /> 11 " t�f25 � <br /> : � (signature ofC-67 hoensed authorized represerrtative), <br /> hereby authorize(print name)_ &Al 5WZ2 02 L-.FR RLJJ � l'yVf:- <br /> to sign this San Joaquin County Well P r mit Application on my behalf. I understand thin authorization is valid for <br /> one(1)year and is linirted to the wax plan dated on the front page of this application. <br /> 6-17-2000!MI <br />