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r �t <br /> f <br /> $an J aqum Gcurtty En�rlronmcntal Hea3tly rYfss�s,Unit IV w4ell � nitA piit:atl t�Skc}�IRfarnent i <br /> ,SOB ADDRESS: <br /> a 3`t potmrr <br /> LICENSED CONTRACTORS DECLARATION <br /> I hemby affirm that I om Gcansed Ander this provisions of Chspter9(commencing with SecAlan 7004)of Division <br /> 3 of the$usIness and Profas53ans Coda and my llcensn Is in full fracas and effeftct <br /> EViration Date: <br /> Bate: Contractor: — <br /> Signature: Title: 1 EN <br /> r T f <br /> Printed name: <br /> WORKERS'COMPENSATION DECLARATION � <br /> } • <br /> I hereby affirm under penalty of perjury ane of the following Oex°laratauris: (CHECK ALL THAT APPLY) <br /> I have and vAll r-naintain a carllfic:ats of consent to self-Insure for workers'eornpen4ation,as provided for by I <br /> ! Sa3eiion 3700 of the Labor C de,for the per#arinance of the work for which this permit is issued. <br /> f I have end will maintain workers'compensatlon insurance,as required by!seclion 3700 of the Leber ode, <br /> for 1he performance of the work for which this permit is Issued. My warksrs'compensation Insumr:ce <br /> mrdier and polis numbers are: i <br /> i <br /> � t t <br /> Carrier 5jl l _ Policy Number. <br /> I certify that in the performance of Me worst for which this permit is issued. I shalt not employ any parson in <br /> any mariner so as to become sut)lect to the workers'tompenSaktian laws 4 California.and agree that it 1 <br /> should become subject to the workers'compensation ptovisions of Section 3700 of the Labor Code,I shalt <br /> forthwith comply with thoGn provisions. <br /> lSate: Signature; <br /> Printed Nears•; <br /> i <br /> WAIiA INO:FAILURE To SECURE W0W<RR5'CcmPENsAT1oN COVERAQE 18 UNLAWFt7L,AND SMALL suejecr <br /> AN EMPLOYER TO CRWINALPENALTIES AND CIVIL FINES up YO ONE HUNDRttU THQBSAND DQ ARS <br /> J1100,000.� IN ADDITION TO THE COST OF CL7I riNSAMON,INTEREST,ATTORNErS rEES,AND DAMACaES AS <br /> PROVIDED FOR IN SE"ON 3708 OF THE LABOR C00C <br /> � � �67f�3�L C.. �� (C,5�'Iteeny,ed alUtTS�rI�aO a^oRC�suntativxl,hea+�&y <br /> aufftQrft4 r r GI' Dsho&JrY .)7&l�FL. [7[ = �Dt en&166 .., <br /> to sign this Sari.foacttrin County Well Pea'mltAcroilcaatlan on any behalf. 1 understand thin 80hari2ation is valid for <br /> etre(1)year*nd Is uarrlW to the work plan dated an tho front Page of this app4cation, <br /> 5.17.2000 1 Ml <br />