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` Q002 <br /> 10/03/2003 FRI 14:00 FAX <br /> _ fetner" <br /> �nvirontinental Health S�Ntce�,l3n[tiV 1Atell'.Permit.AppSicatiot�S�ipP. <br /> San Joaquin County /Z �PER�VII 5R �5 5 2-0 <br /> JOB Apt3RESS: �P <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> 1 hereby affirm that I am licensed under the provisions of Chapter 8 (torr+merrcing with Section 7000)of Div Won <br /> 3 of the Business and professions Code and my i•�oeC►se is in full force and e[ec . <br /> �••y sl �,y �Expiration bate: <br /> License#: !G� �C <br /> D 3D25 pontractor. <br /> Date:— � --- <br /> 3 Title' C� <br /> Signature: <br /> printed name: �^ <br /> WORKERS' COMPENSATION MCLARA.TfON <br /> 1 hereby affirm under penalty of perjury one of <br /> THAT APPLY) <br /> f the following declarations: (CHECK AL <br /> have and Witl maintain a certificate of consent to self-insure for workers' compensation, as fxovided for by <br /> -"I have <br /> and <br /> wi'of the Lobar Code,for the performance of the work for which this perrnit is issued. <br /> 3700 <br /> 00 of the Labor <br /> I have and will maintain workers' compensation insurance, as required by Section nsation insurance ode <br /> for the performance of the work for which this permit is issued. My workers' compe <br /> carrier and policy numbers are: <br /> !> I t✓�� - Policy Number: <br /> Carrier: ' <br /> that in the performance of the work for which this permit is issued, t shall not employ any person m <br /> and agrees that It i <br /> 1 certify 1 shall <br /> any manner so as to become subject to the Workers' compensation l3vsrs of California, <br /> should became Subject td the workers'compensation provisions of Section 3700 of the Labor Code, <br /> forthwlth uc mp yawith diose provisions, <br /> Date: Signature: <br /> ��('ll � <br /> Printed Name= i� <br /> FUL,AND SHALL <br /> WARNING;FAILURE TO SECURENALT ES RNDOMPL F NES UP TO ONE HUNDRED 1-tOUSAND DOLLARS <br /> Aly��9PLoY1=R TO cRIMIt�aL Pf* <br /> (y40D,000_),IN ADDITION TO 9706 COSI OF <br /> OF THE LCOMpENSATIABOR ODEON,INTEREST,ATTORNEY'S FEES.AND DAMAGES A <br /> PROVIDED FOR IN 56GTION <br /> (C-57 Ii cnsend authorized representative), her'cW <br /> autiioriza <br /> to sign this San Joaquin County Well permit Application on my behalf. I understand this autharizatlon is valid os <br /> one il�year^and is limited to the wOr_k PI?n dated on the front age Of thks ap <br /> WUN 1 WVvS'0 1 E56G 17V0-nf <br />