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San Joaquin County Environmental Health Services, Unit IV Well Permit Application Supplement <br /> JOB ADDRESS:,�5D3 AV -s, PERMIT SR#: <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> i <br /> I hereby affirm that I am licensed under the provisions of Chapter g(commencing with Section 7000)of Division <br /> 3 of the Business and Piofess+ons Code and my license is in full force and effect. <br /> IT tGc Ex iraliori Me: f —30-02 <br /> License#. i Q P <br /> Date: 17 Contractor: <br /> AA rC Title: <br /> signature: <br /> Printed name: w 3 77"0/4 P. <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 setFinsure for workers'comperuation,as provided for by , <br /> Section 3700 of the Labor Coda,for the performance of the work for which this permit is issued. <br /> I have and will maintain workers'compensation insurance, as required by Section 3700of he LaborinsurancCode, <br /> for cite performance of the work for which this permit is issued. My workers'comps <br /> nsationcarrier and policy numbers are <br /> : 77L+✓ . oticNumbar10 <br /> Carrier; f � <br /> i <br /> I certify that in the performance of the work for which this permit i5 issued,I shall not employ any person in I <br /> the workers'co <br /> any manner so as to become subject to k ' mpensation Laws of California, and agrea that if I <br /> should become subject to the workers'compensation provisions Of Section 3700 Of the Labor Code,I shall <br /> forthwith comply with those provisions. �f <br /> Date:. 6—S011 Signature: <br /> Printed Name: <br /> WARWNG: FAILURE TO SECURE WORKERS'COMPENSATION COVEftAGE Is UNLAWFUL,AND SHALL SUBJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CML FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> PSROVIDED IN FOR IN IMN TO THEM F THE I.COMPENSATION,INTEREST,ATTORNEY'S FEES,AND DAMAGES AS <br /> 1 /(�G-f,t�� (signatum oIC-57 hoenaed authorized repreeerrtative), <br /> hereby authorize(print name) /LeA/ KWA/Z O/ L-FX /{fP1Z4PA-" ! yyf <br /> to sign this San Joaquin County Well Permit Application on my behalf. I understand this authorization is"lid for <br /> one(1)year and is limited to the writ plan dated on the front page of this application. <br /> 6-17-2000 1 MI <br />