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10/27/2000 09:34 71-26764 <br /> EAI <br /> PAGE 03 <br /> San Joaquin County Environmental Health Services,Unit IV Well Permit Application Supplement <br /> JOB ADDRESS: San Joaquin De1ta College PERMIT SR#• <br /> 5151 Pacific Avenu® <br /> Stockton, California <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> I hereby affirm that I am licensed Under the provisions of Chapter 9(Commencing with S¢ctlon 7000)of Division <br /> 3 of the Business and Professlons Code and my license is in full force and affect- <br /> Expl2tion Date:- In r 3� <br /> Date: actor, <br /> Signature: <br /> • -- Title: <br /> Printed name: <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of She following declarations. (CHECK ALL THAT APPLY) <br /> I have and will malntaln a cer"Icsta of Consent to self-Insure for work®rs'compensation,as provided for oy <br /> Section 3700 of the Labor Code, 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 3700 of lhq Labor Code, <br /> for the performance of the work for which this permit is issued. My workers'comp ensstion insurance <br /> carrier and policy numbers are <br /> .- <br /> Carrler. ia Policy Number, S 6r)Q0s <br /> I certify that In the performance of this work for which this permit is issued, I shall not employ any peon In <br /> any manner so as to become subject to the workers•compensation laws of Celifomia, 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 Comply with those provisions. <br /> Date ill. Q—Q0 _Signature (}� <br /> ht <br /> Printed Name <br /> WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE 19 UNLAWFUL,AND$HALL SUBJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> (S`100,00ll IN I uomON TO THE COST OF COMPENSATION,INTEREST,ATTORNEY'S FEES,AND DAMAGES AS <br /> PROVIDED FOR IN SECTION 370/6 OF THE LABOR CODE. <br /> b- L_—G,c, Laan�SfJ C• <br /> •�1 ( 571ioenaed authorized reproeentadve),hereby <br /> '7" i <br /> to sign this San JoaquM County Well Permi3 Application an my behalf. I understand this aurhaHzation is valid for <br /> one (1)year and Is limited to the work plan dated on the front papa of this application. <br /> 5-17-2000/101 <br /> Z abed `•OO:OL 00-0E-130 ` ( ' <br /> •ZOEO ElE 5Z6 '3uI 6uils01 'R OuTT7u0 660J0 :/rg luag <br />