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06/14/2004 09:07 209468 3 FIFTH FLOOR <br /> i <br /> San Joaquin County Environmental Health Department Unit IV Wel)Permit Application Supplement <br /> JOB ADDRESS: PERMIT SR#: <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> I hereby affirm that I am Ileersed 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#: ���/l o S Expiration Date: � / 0 <br /> Date: Co ctor: <br /> Signature: Title: <br /> Printed name: <br /> I WORKERS' COMPENSATION DECLARATION <br /> 1 hereby affirm under penalty of perjury one of the following declarations. (CHECK ONE) <br /> .i.,l have and will maintain a certificate of consent to self-Insure for workers compensation, 2s provided for s <br /> by 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 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: i <br /> I <br /> ,/ i <br /> Carrier. Ca Policy Number: ,6/U l <br /> I <br /> I certify that in the performance of the work for which this permit is issued, I shall not employ any person in i <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 /> Expiration Date: 0 Signature: / <br /> Printed Name: a <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,ATTORNErs FEES,AND DAMAGES AS <br /> PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. <br /> AUTHORIZATIONOR OTHER THAN C-57 SIGNING PERMIT APPLICATION i <br /> I, (signature ofC-S7 licensed authorized representative), <br /> hereby autho ' (printname) iii Villariuek-&- <br /> to sign this San Joaquin County Well Permit Application on my behalf. I and land 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 /> 8-29-021 N <br /> EHD 79.02-001 <br /> 9/30/2003 <br />