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DEC 2 3 2002 <br /> ENVIROWiIIEJT HEALTH <br /> PERMIT/SERVICES <br /> San Joaquin County Envir enta ealt�i Services,U Ita eti PennitApplication Sup�ptement <br /> JOB ADDRESS: RMIT SR#: DO 32 32� <br /> d'-1�u ' ' 1 <br /> sR # o U 32 3 2 <br /> LIC NSED 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. j <br /> License#: <br /> /� Qy Expiration Date: �,4RQZC <br /> Date: <br /> ontractor: <br /> Signature: <br /> Title- <br /> Printed name vi <br /> - <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 /> 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 <br /> policy <br /> onumbers are: _ <br /> Carrier- ft�T. I Ltl—)C1 Policy Number: <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 clomplyrmith those provisions. <br /> Date: <br /> I Signature: <br /> y <br /> �rvd r <br /> Printed Name: g r a it <br /> O <br /> AWARNING; FAILURE TO SECURE N EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARSUBJECT <br /> ( ISECTION ADDITION TO <br /> HE COST OF LABOR OFCOMPENSATION,INTEREST,ATTORNEY'S FEES,AND DAMAGES AS <br /> PROVIDED FOR <br /> I (C-57 licensed atrized resentative), hereby <br /> authorize <br /> ppl ation on my behalf. I understand this au horization is valid for <br /> to sign this San Joaquin County Well Permit <br /> one(t)year and is limited to the work plan dated on the front page of this application. <br /> 1 <br /> W02id INV175'01 6661-90-01 <br />