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Fe'd 7Hioi RECEIVED <br /> APR 2 7 2001 <br /> San Joaquin County Environmental Health Services, Unit IV Well Permit Application Supplement <br /> JOB ADDRESS' 7 A&0Ar PERMIT SR#: <br /> LICENSED CONTRACTORS DECLARATION (LCD) <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#:J12A& ofExpiration Date:�Z <br /> Date: Contraci �U <br /> Signature: Title 1/ { <br /> Printed name: <br /> 2;Liu� y,6!aZw <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm under pena4ty of perjury orie of the foitowing declarations: (CHECK ALL THAT APPLY) <br /> 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 ll�Cf{/���/V 4zm Policy Number:__M6eD-32� 6D <br /> I Certify that in the performance of the work for which this permit is issued, I shall not employ any person in <br /> T 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 o P <br /> Section 3700 of the Labor Code, I shall <br /> forthwith Pomply with those provisions. <br /> Date: Signature: <br /> Printed Name: i64�f'f�lT� <br /> i <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.), IN ADDITION TO THE COST OF COMPENSATION,INTEREST,ATTORNEY'S FEES,AND DAMAGES A5 ! <br /> PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, <br /> I, '.(signature ofC-57 licensed <br /> "authorized representative), <br /> hereby authorize(print name) / )(-< /7/= l: �/j� <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 to the workplan dated on the front page of this application. <br /> s-17-20001 MI <br /> FO/zit'd TZt7L V9E 6SS ONS3dd X I didW039 Ee:t7 T T 002-2u-ddH <br />