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02 / 06/ 2003 T)RI 08 : 01 FAX �jppp <br /> d <br /> San Joaquin County Environmentr Heaa th Services , Ul It V WV Well PermA PPIIcFtlon Supplement <br /> JOB ADDRESS ; td PERMIT SOW ' <br /> 1 G <br /> LICENSEDCONTRACTORS DECLARATION (LCD) <br /> 1 hereby affirm that I am licensed under the provisions of Chapter g (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 af: r�fn}�—� � _ Expiration Date: O - <br /> Date: _ a - _ omractor: 7 / " <br /> Signature: 1,, ) Title: <br /> printed n0 <br /> ame: gJ <br /> JL <br /> VIrORKERS ' COMPENSATION pECLAi@ATION <br /> I hereby affirm under penalty of perjury one of the following declarations; (CHECK ALL THAT APPLY) <br /> mpensatin, as <br /> �/ <br /> Section 37001of the Labor code,ffor the performancete of consent to -insure for of the work forkwhich othis permits issued.ured Tor by <br /> V/ I have and Will maintain workers' compensation Insurance, as required by Section 3700 of the tabor Code, <br /> for the performance of the work for which this permit is issued. My workers' compensation insurance <br /> carrier and <br /> policy <br /> numbers are: <br /> Carrier: i. _iI� <br /> tI - Polic7fNumbcr: �1�._.�' <br /> I certify that in the performance of the work for which this permit Is issued , I 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 Sion 3700 of the Labor Code, I shall <br /> fohw th those provisions, <br /> Date: <br /> Signature ; <br /> Printed Name; �ll�-L-t" f!y-".� <br /> WARNING: FAILURE TOSECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL SUBJECT <br /> AN WPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND AOLLARS <br /> ($To0,0a0.), IN ADDITION TO T14E COST OF COMPENSATION, INTEREST, ATTORNEY'S FEES, AND DAMAGES AS <br /> PROVIDED FOR IN SECTION 3706 OF THE LA13OR CODE' <br /> �� G57 licensed oath o:ae�representative), hereby <br /> authorizo <br /> to sign this San Joaquin County Wela Permit APPIlcetion on my behAlf. I understand this authorization is valid for <br /> ono year and is Ilmlted to the work plan dated on the front page of this application. <br /> wc_ir,+.-I l•Iry� ' rt l 66bl - VO-CJ '. <br />