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07/22/2003 TUE 14:58 FAX Z1003 <br /> San Joaquin County Environmental Heaith Services,Unit.IV WC-11 Permit Application Supplomeolt <br /> JOB ADDRESS: VC,& E tC��.Jvc PA,<-�.�r� PERMIT' SES#: <br /> �fc,�C-v <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> I hereby attirm that I arrr licensed tinder the provisions of Chapter 0 (commencing with Section 7000) of Division <br /> 3 of thA Etusiness and Professlons Code and my lir ensE is in full force and effect. <br /> Lk=erase#: ,7SQ Expiration pate: — <br /> p ate: fj' <br /> ontractor: f <br /> Signature: Title: <br /> �-l��' '" <br /> Printed name: — <br /> WORKERS' COMPENSATION DECLARATION <br /> her�sby Aff,rm under penalty of perjury one of the following declarations: (CHECK ALL THAT AI I-Y) <br /> 1 haveon 3d 001ot maintain a <br /> Labor Code,for the pertormancete of consent to fof the work forkwhich th compensation,permis issuerdvided fr�r by <br /> Sear <br /> I have and will maintain workers' compensation Insurance, as required by Section 3700 of the Labor C=ode, <br /> for the performance of the work for which this permit is issued. My workers' compensation insurance <br /> carrier and policy numbers are: }f <br /> Carrier: <br /> C �,� ` Policy Number: ` r � <br /> i <br /> _i ccftify that in the performance of the work for which this permit is issued, i shall not employ any person tin <br /> any manner so as to become subject to the workers' compensation laws of California, and agree that if 1 <br /> should become suNect to the workers' compensation provisions of Section 3700 of the Labor Code, 1 shall <br /> forthwith corn with those provisions. <br /> /r f <br /> Date: ' Signature: _ --� <br /> Printed Name: <br /> WARNING: FAILURE TO SECURE WORKERS, COMPENSATION COVERAor; Is UNLAWFUL.,AND SHAT.-L SUBJECT <br /> AN EMPLOYER TO CRIMINAL.PENALTIES AND GIViI-FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> ADDIT)ON TO THE COST SECTION 37 6 OF THELABOROra COD7=_ <br /> C ON' INTEREST,ATTORNEY'S FEES,AND DAMAGFS AS <br /> PROVIDED FOR <br /> 7 <br /> r;censed authorized representative), hcretry, <br /> authorize <br /> to sign this San Joaquin County Well Permit Application on my behalf, I undorsland this authorization is valid fes <br /> one(1)�r and is limited to tic work plan dated on the front page of this application• <br />