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rQGCO. INC. 916r-61942 P. 03 <br /> San Joaquin County Environmental Health Services,Unit IV ilVeli Permon supple,Applicatile en <br /> 3; <br /> JOB ADDRESS: PERMIT SR#:©d� 7 9 <br /> �. <br /> — <br /> ` E f <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> i_ i hereby affirm that I am licensed under the provisions of Chapter 9(commencing with Section 7000) } <br /> ' L` 3 of the Business and Professions Code and my license is in full force and effect. of Iviion <br /> III <br /> License#; _Expiration Date: 7`,(N I <br /> Contractor: <br /> Vale: Gn Gu 1�1 L i <br /> ' <br /> i Signature: Title; I <br /> _- <br /> �� <br /> 0- <br /> Printed name: i <br /> WORKERS' COMPENSATION DECLARATION <br /> i i hereby affirm udder 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 provide for y <br /> M� Section 3700 of the Labor Code,for the performance of the work for which this permit is issued, <br /> j have and will maintain workers' <br /> compensation insurance,as required by Section 3700 of the Labor Co s, <br /> for ilia performance of the work for which this permit Is issued. pAy workers'compensatipn insuranc <br /> carrier and policy numbers are: <br /> f <br /> i" ` 1 <br /> Carrier: _�jif ,end —Policy Number:. 1�:Jo I- <br /> I certify that in the performance of the work for which this permit is issued, Is <br /> hall notemploy any per on <br /> any manner so as to become subject to the workers'compensation laws of California, and agree tha if I <br /> gar should become subject to the workers'compensation provisions of Section 3700 of the tabor Gode; <br /> forthwith comply with those provisions. shall <br /> Date: 1�Z-�•�o© Signature' l <br /> ;. Printed Name: <br /> C, <br /> WARNING: <br /> WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJE <br /> AN EMPCOYER TO CRIMINAL PENALTIES AND CIVIL FINE$Up TO ONE HUNDRED THOUSAND DpLLARS i <br /> ($100,000.),IN ADDITION TO THE COST OF COMPENSATION,INTEREST,ATTORNEY'S FEES,AND OHMAGE AS <br /> PROVIDED FOR IN SECTION 3706 OF TH5 LABOR CODE, i <br /> (C-57 licensed authorized representative)' <br /> ' ,hereby <br /> t suthorIze. <br /> _ U� fllJlt,�..Q 1 <br /> to sign this San Joaquin County Well permit Application on my behalf. 1 understand this authorization is�a11 for <br /> Ono(1) r } <br /> year and Is limited to the work plan dated on the front page of this appllcatfon. } <br /> 5-17-20001 Ml f <br /> ``7J 39 VJ <br /> ----- ------------ <br /> --------- ------ EIrbS89ti60z 0£=Zt 000irlll/'i t i <br />