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10/13/2000 10:57 20946834?3 FIFTH FLOOR <br /> v <br /> San Joaquin County Environmental Health Services,Unit IV Well Permit Application Supplement <br /> JOB ADDRESS: 19 5-4, N . 06:3L­!n `19 PERMIT SR#: 00 ? 15 <br /> LICENSED CONTRACTORS DECLARATION LCD <br /> I hereby affirm that I am licensed under the provisions of Chapter 9(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#: zo Expiration Date.- <br /> Date: <br /> ate:Date: }/ (L, Q�. Contractor: rl1 rA* <br /> Signature. `� —tel Title: ( 1 <br /> „ Me <br /> Printed name' Ariy/,d F 'W <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the following declarations: (CHECK ALL THAT APPLY) <br /> 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 /> .//,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' Compensation insurance <br /> carrier and policy numbers are: <br /> Carrier. s Q n Policy Number; <br /> IF <br /> I Certify that in the performance of the work for which this permit is issued, l 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 comply with those provisions. <br /> Date: �Oy Signature: <br /> Printed Name: 7:04t✓i <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 HUNDRED THOUSAND DOLLARS <br /> ($100,000.),IN ADDITION TO THE COST OF COMPENSATION,INTEREST,ATTORNEY'S FEES,AND DAMAGES AS <br /> PROVIDED FOR IN SECTION 37DE OF THE LABOR CODE. <br /> 11 (C-57 licensed authorized representative),hereby <br /> authorize <br /> to sign this San Joaquin County Well Permit Application on my behalf. 1 understand this authorization is valid for <br /> one(1)year and Is limited to the work plan dated on the front page of this application. <br /> 5-17-20001 MI <br /> OCT-13-2000 FRI 10:59A11 ID: PACE:3 <br />