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AUG 09 2002 11:29AM HF LASERJET 3200 <br />uzt zvuz 11: id 2094E )2 rIPTH FLOOR <br />P.1 <br />PAGE 82 <br />San Joaquin County Environmental Health Services, Unit IV Well Permit Application Supplement <br />JOB ADDRESS: Wit S6)1, t(A/ , PERMIT SR#: 6e,9IE-61 2- <0613054 <br />41 <br /> <br />J5 rd <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. <br />LICENSED CONTRACTORS DECLARATION (LCD) <br />Policy Number: ---/ <br />Printed Name: <br />(signature ofC-57 licensed authorized representative), <br />License #. <br />Date: <br />Signature: <br />Printed name: <br />Expiration Date: <br />ContLItor C.:1 re?71,;/ <br />Title: <br />a r 66dclo' <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 /> 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 L-C2 5ii/7 <br />I certtfy 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 taws of California, and agree that if I <br />should become subject to the workers' compens tion provisions of Section 3700 of the Labor Code, t shall <br />forthwith comply with those provisions. <br /> <br />Date: °I Signature: <br />/24 <br />WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br />(6100,000.), IN ADDITION TO THE COST OF COMPENSATION, INTEREST, ATTORNEY'S FEES, AND DAMAGES AS <br />PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. <br />N&-( <br />hereby authorize (print name) Y-/ i< 7 Q,-. I (=-1X) <br />to sign this San Joaquin County Well Permit Application on my behalf. ( understand this authorization is valid for <br />one (1) year and Is limited to the work plan dated on the front page of this application. <br />5-17-2000 / Ml