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FROM FRX NO. : D_,,. 14 2006 04:241`1`1 P9 <br /> San Joaquin County Environmental Haelth oepartment Unit IV Well Permit Application Supplement <br /> JOB ADDRF-99: 's //"h L d ,� �„ 9_ PERMIT SR#'�..�_ <br /> LICENSED CONTRACTORS DECLARATION LI&O <br /> I hereby affifrn that I am licvneed under the provisions of Chapter 9(commencing with Section 7000)of Division <br /> l3 of the Business and Profeeslons Code and my lioenev Is in full force,and effect)40 Lloense?>w: Fxpiration Date: 0,5 <br /> Date: 010 Contractor: yVl 3 C Q� <br /> Signature- Tide: yxtf. <br /> 1� <br /> Printed name: <br /> WORKERS' COMB SAT30N DECLARATION <br /> I hereby affirm under penalty.of pedury one of the folloMng deeiarations_ (CHECK ONE) <br /> _ I nave ana will m?Untain a certificate of consent to self-insure for wofkers'compensation, as provided for <br /> bySoeion 3700 W the Labor Code,for the performance of the wom for which this pafmit is Issued. <br /> 4.111 vySe and will maintain workers'compensation Insurance, as required by Section 3700 of the,Labor Code, <br /> + for the performance of the work for whlah this permit is issued. My wwkert;' cvrnpensation Insurance <br /> carrier and policy numbers re: <br /> f r� <br /> Carrier: Ja C Policy Number et2 �K-�.( j <br /> i oertify that in the pelfommanCe of the work for which this permit re eaued,I shall not employ any person in { <br /> any manner so as to become subject to the workors'compensation laws of Caiifornia,and agree that if f <br /> should become subject to the worker' compensation provislons ot Section 3700 of the Labor Cade, I shall <br /> forthwith Wmply with those provisions. <br /> Expiration Date: Signature: c—' <br /> Printed Name: <br /> WARNING:FAILUR!YinSECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL, Nos NALL SUBJECT <br /> AN>�MPLOYER TO CRIMINAL PINALTIED AND CIVIL FINES UP TO ONE HUNDRED THOU ND DOLLARS <br /> ($i 0o,000.),IN ADDITION TO THE C09T OF COMPENSATION,INTEREST,ATTORNE"Fal <br /> 3,J <br /> ,ANDDAMAGI'8 Ami <br /> PROV113ED FOR IN SECTpON 3706 OF THE LABOR CODE. <br /> AUTHORtZ/A ON F(�7�?QO�T—HER THAN C-ST SIGNING PERMIT APPLICATION' <br /> i11lpnaeuraW-57Ilavnoed auttwAred reprssenta voL <br /> Md <br /> irortby authariza(print name) <br /> to sign this san Joaquin County!Nell permit Appilc#Uon on my behalf. 1 understand this■utharixation le valid for <br /> one(i)year and Is limtted to the work plan dater!on tho front Paye d this■ppilostion, <br /> e,xs-0T/ImN <br /> PHU 29-0201 <br /> 22Z0� <br /> 50 3Jtyd iilViSCV3H d3HiVW �LZ01EZ 8S:8T 9002/DZ/ZT <br />