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NRR 24 2003 11 : 59RM HP LRSERJET 3200 P. 1 <br /> Mar-24. 2003 1 .051M ')03 EARTH ?EONOLCGIES No-3191 P. 2/2 <br /> San Joaquin County Environmental Health Services,Unit IV Well Permit Application Supplement <br /> JOB ADDRESS;_/.9,5? A'y& sl WISUVS PERMIT SR#: 0D35.302. <br /> LICENSED CONTRACTORS DECLARATION (LCD) <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 it: (ff / Expiration Date: <br /> Date: Contractor: <br /> Signature; Ting: Qx7'�dYJ /�(Q.�ta01 <br /> - <br /> Printed name: Q I' 0 <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the following declarations: (CHECK ALL THAT APPLY) <br /> 1 have and will maintain a certificate of consent to self-Insure for workers' compensation,as provided far 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 num0ers are: <br /> Carrier ,U7Policy Nurnber- <br /> 1e 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 Section 9700 of the Labor Code, I shall <br /> forthwith comply with those provisions. <br /> Dater Signature: <br /> Printed Name: / !lrrl ✓� � --'' <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.),1N ADDITION To TME COST OF COMPENSA710N,INTEREST,ATTORNEY'S FEES,AND DAMAGES AS <br /> PROVIDED FOR IN SECTION 3706 OF THE LA13OR CODE. <br /> (C-57 licensed authorized representative), hereby <br /> authorize &. e.trAJf- &YA& M&M 4ly-602t-4 &R. Day ZSCOXQ <br /> to sign this San Joaquin County Well Permit Application on my behalf. I understand this authorization Is valid for <br /> one(1)year and Is limited fo the work pian dated on the front page of this application. <br /> 5.17.20001 MI <br />