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FEB 23 2004 10: 13AM H' RSERJET 3200 P. 1 <br /> San Joaquin County Environmental Health Department Unit IV Well Permit Application Suppleme tt <br /> JOB ADDRESSz;2AJ &OJ'/S 6L �O y PERMIT SR*.003 5 <br /> LICENSED CONTRACTORS DECLARATION i(LCD) <br /> I hereby affirm that I am licensed under the provisions of Chapter 9(commencing with Section 7000)of Olvi"On <br /> 3 of the Business an <br /> P�ro�f7(� <br /> ode and my license is in full force and effect. <br /> License fk � rQ Expiration Date: <br /> Date: Contractor: <br /> f <br /> Signature: — Title <br /> r > <br /> Printed name. ,( <br /> WORKEiRS'CONIPENSA TION DECLARATION <br /> I hereby affirm under penalty of perjury one of the following declarations: (CHE=CK ONE) <br /> _ <br /> (he a and will maintain a certificate of consent to self-Insure for workers'Cornpe,kation,as provided for <br /> Section 3700 of the Labor Code,forthe performance of the work for which thc;permit is issued. <br /> I have and will maintain workers'compensation insurance,as required by Section 3700 of the Labor Cc de, <br /> for the performance of the work for which this permit is issued. filly workers'com:ensation insurance <br /> carrier 2nd policy numbers are. <br /> <br /> : <br /> I certify that in the performance of the work for Which'his permit is issued, I shall riot employ any perscr in . <br /> any manner so as to become subject to the workers'compensation laws of Calift:6a,and agree that i1 <br /> should become subject to the wotkers'campen tior provisions of Section 3 o of the Lsbor Cede,I si tiall <br /> forthwith comply with those provisions. <br /> Date: _� Signature: :---=- —_ <br /> Printed Name: <br /> WARNING:FAILURE TO SECURE WORKERS'COMPENSA i10N COVERAGE 4 UNLAWF IJL,AND SHALL SIJ®JI:CT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP :TO ONE HUNDRED THC QSAND DOLLARS <br /> (5100,000.1,IN ADDITION TO THE COST OF COMPENSATION,INTEREST,Ai7ORNEY S °EES,AND DAMAGES %S <br /> PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. <br /> AUTHORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> 1,_�1,Sa:kj d_— (S19nature afC-67licensed auttlorlred representat wl, <br /> hereby authorize(prtnt r whe) <br /> to sign this Saar Joaquin County Well permit Appticatiar,or,my behalf. I and land this authorization is valid I or <br /> one(1)year and Is lknited to the work plar,dated en the front page of this application. <br /> e-zs-oz t tat _ <br /> 00/Z0 39dd N017tCCJ15 3Ob EiLTL9�60Z 10:60 tel DZ/£Z/Z0 <br />