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r p <br /> DEC 2 3 2002 <br /> ENVIROMMEN F HEALTH <br /> ERMITiSERVICES <br /> San Joaquin County E r enta{Healt{�Services,U it f ell PermitARPI'cation Supplement <br /> `\J I` nIJ} RMI`I" SR#' 00 32320 <br /> JOB ADDRESS: sR >y -TO-32-3 2 <br /> LIC NSED CONTRACTORS DECLARATION (LCD) <br /> 1 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 /> riooqollExpiration Date: � <br /> License#: <br /> ' contractor: <br /> Date: <br /> Title: fir'/b�LtA�JI i <br /> Signature: <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 /> V1 1 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: <br /> }t(J� Fl ll � Policy Number: 711 -Z) <br /> _I 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 3700 of the Labor Code, 1 shall <br /> forthwith cprr�plylwith those provisions.-1 ZII/aN <br /> Date: <br /> Q 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 /> PROVIDED FOR IN ON 3706 OF T LABOR ADDITION TO THE COST <br /> OFCOMPCODEENSATION,INTEREST,ATTORNEY'S FEES,AND DAMAGES AS <br /> (C-57 licensed a rized resentative), hereby <br /> authorize <br /> to sign this San Joaquin County Well Permit PPI ation on my behalf. I understand this au rization is valid for <br /> one(1)year and is limited to the work plan dated on the front page of this application. <br /> N <br /> . W02ld WVVS'0l 6661—D0—Dl <br />