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FROM : FAX NO. Dec. 14 2006 04:20FM P3 <br /> San Joaquin County l=nv)ronmenfal tie2Jth Depsrfmont Unit IV Wen Permit Application Supplement <br /> JOB ADDRESS; CD4 A � J4 d <br /> PHRMIT SRO.- <br /> LICENSED <br /> Rilt:LICENSED CONTRACTORS DECLARATION (LCD) <br /> I hereby affirm that I am licensed under the provleione of Chapter 9(commencing with Section 7400)of Division <br /> 3 of"Duetness and Professions Code and my license Is in full force and eff6vt, <br /> LicenseI G3tXplr2ktion Date, D��d Co tracto <br /> Signature: <br /> Printed name- <br /> WORKERS'COMPENS N DECLARATION <br /> 1 hereby affirm under penalty of perjury one of the folloWng declarations; (CHECK ONE) <br /> I have and will maintain a certificate of conpent Iv nelf-Insure for workero'compensarlorr, as provideq for <br /> ZI <br /> Section 3700 of the t..ab*r Code,for the performance of the work for which thio permit is issued. ' <br /> ave and wilt 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'oenmpensation insurance <br /> carrier and polley numoa are: { <br /> Carrlw,. Polley Number: /Z� Iry 01` -/ <br /> I certify that in the performance of the work for which th4 permit IS iR6ued,r shall not employ any person in <br /> any mwnncr so as to become subject to the workers'compensation laws of California,and agree than If I <br /> should become subject to the workers' compensation provisions of Seamon 3700.6f the Labor Code, I%hall <br /> forthv0th comply with those <br /> �1 pcvisions, <br /> EKplratlbn Dao: /, gtature: <br /> Punted <br /> r Iij <br /> Name: �`� IA—) <br /> WARNING:FAILURE TO SECURE WORKERS'COMPEN19ATION COVERAGE in UNLAWFUL.,'AND SRALLL SUBJECT <br /> AN EMPLOYER Ta CRIMINAL PENALTIES AND CIVIL FINES UP To ONE HUNDRED THOUSAND DOLLARS <br /> (3100,GOt1.),IN ADDITION To THE COST OF COMPENSATION,INTEREST,ATTORNEY'S FEES,AND DAMAGES AS <br /> PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, <br /> AUTHORIZATION F QTHER THAN"7 SIGNING PERMIT APPUCATION. <br /> (:ignalure otG-S711 need authorize <br /> d representative), <br /> hereby authorize(print namet <br /> to sign this aan Joaquin County Well Pkrntit APphterivn on my behalf. I underatond this outhortaetion Is valid for <br /> one(1)year and is limited to the work plan dated on the front page of this appllastion. <br /> tt,2Y-02!Atm <br /> aHLf 29-�-0O1 <br /> Q22r0o <br />