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03/26/2002 TUE 1.1:03 FAX [a 001 <br /> 03/26/2002 13: 33 4640138 ENVIRONMENTAL HE, PAGE 01 <br /> San Joaquin County Environmental Health Department Unit IV Well Permit Application Supplement <br /> JOS ADDRESS: C ; ,.�, dos PERMIT SR#; <br /> LICENSED CONTRACTORS DECLARATIONL(. CD1 <br /> 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 - `/ Expiration pate: <br /> Date: �n c�.� �f .?/}i2 Contractor: <br /> Signature: Z Title-, <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 Code, <br /> for the performance of the work for which this permit is issued. My workers'compensation insurance <br /> carrier and policy numbers are: <br /> Carrier, _ Policy Number: <br /> I certify that in the performance of the work for which this permit is issued, I -,hail 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 Codi, I shell <br /> forthwith comply with those provisions. <br /> Da to: Signature: <br /> Printed Name: <br /> WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL GUBJr-CT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND UDLLARS <br /> ($100,000.), IN ADIDWON TO THE COST OF COMPENSATION,INTEREST,ATTORNEY'S FIFES,AND DAMAGES AS <br /> PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. <br /> I (slgnaturn ofG-s7 licensed authorized ropmsentative), <br /> hereby authorize (print name) <br /> to sign this San Joaquin county wall Permit Application on my behalf. 1 understand this authorizatlon is valid for <br /> one (1)year and Is limited to the work plan dated on the front page of this application. <br /> 125-02/MI <br /> o3/26/z002 TUE 13:26 CTX/RX NO 68821 Z 001 <br />