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06/11/2002 TUE 10:47 FAX . 12002 <br /> p6[,1i02 TUE 11:20 FAX 1 916 60400 SECOR-SACRAMENTO i®002 <br /> xa,x <br /> Sar, Joaquin County Environmental Health Services, Unit IV Well Permit Application Supplement <br /> 0030 2-03 <br /> JOB ADDRESS;Z'�69����bs 5, Sar• Fe P�1, PERMIT SR#:� 0 02U <br /> ;Z1 mriam 1L. <br /> LICENSED CONTRACTORS DECLARATIONL( CD) <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#: CS"( 72e964 Expiration Date: 4�3o'0� <br /> Date: kA.,e <br /> ( �/ a2. Contractor: <br /> Signature: CG1/�� `T Title: .n� ( – <br /> i <br /> Printed name: <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the following declarations: (CHECK ALL THAT APPLY) <br /> _I 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 /> I have and will maintain workers' compensation insurance, as required by Section 3700 of the Labor Cade, <br /> for the performance of the work for which this permit is issued. My workers' compensation Insurance <br /> carrier and policy num(bers are: <br /> Carrier: ? Policy Number: 7/3 S33`/ -61.1 <br /> I cartily 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 Section 3700 of the Labor Code, I shall <br /> forthwith complywlth those provisions. <br /> Date: Signature: <br /> Printed Name: <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 /> OR, ISECTIIN ON Li P/ /IOO HE COST OF OF THE LABOR COMPENSATION, INTEREST,ATTORNEY'S FEES,AND DAMAGES AS <br /> PROVIDED7 '(/ (signature oTC-57 licensed authorized representative), <br /> I,— <br /> hereby authorize(print name <br /> ) r�4 CQr' <br /> to sign this Sen Joaquin County Well Permit Application on my behalf. I 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 /> 5-17.7000/MI <br />