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Jun 11 04Y04:OOp Mary Walden 9253135715 p., <br />I <br />c4& <br />San Joaquirj County Environmental Health Services, Unit IV Well Permit Application Sup <br />JOB ADDRESS: 25w0 ��� PERMIT SR#: 003E_3 <br />i LICENSED CONTRACTORS DECLARATION (LCD) <br />I hereby affirm t t I am licensed under the provisions of Chapter 9 (commencing with Section 7000) of Division <br />3 of the Busine and Professions Code and my license is in full force and effect. <br />License #: / r�J ,D L/ Expiration Date: / <br />Date: A 16 -VI Contractor: C r e Gid / /lr - S, 7- L <br />Signature: �. <br />Printed name: <br />Title: 6� <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 II maintain a certificate of consent to self -insure for workers' compensation, as provided for by <br />Section 370 of the Labor Code, for the performance of the work for which this permit is issued. <br />Xhave and <br />r the pert <br />carrier and <br />Carrier: <br />I maintain workers' compensation insurance, as required by Section 3700 of the Labor Code, <br />nance of the work for which this permit is issued. My workers' compensation insurance <br />iicy numbers are: <br />Policy Number: 2 /` l'o 0 / 9 0,;2- / 7 <br />1 certify that i' the performance of the work for which this permit is issued, I shall not employ any person in <br />any manner, as to become subject to the workers' compensation laws of California, and agree that if I <br />should becor te subject to the workers' compensa ion rovisions of Section 3700 f the Labor Code, ! shall <br />forthwith comply with those provisions. <br />Date: Signature: f <br />Printed Name. <br />I� <br />WARNING: FAILU E TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL SUBJECT <br />AN EMPLOYER TgCRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br />($100,000.), IN ADDITION TO THE COST OF COMPENSATION, INTEREST, ATTORNEY'S FEES, AND DAMAGES AS <br />PROVIDED FOR INI SECTION 3706 OF THE LABOR CODE. <br />(signature ofCC--5�7licensed authorized representative), <br />hereby authorize( rint name) 1- r� ✓ /L�/�')/17i- �. ! __Z � ,j � Ck <br />—, <br />to sign this San Jo quin County V411 Permit Application on my behalf. I understand this authorization is valid for <br />one (1) year and is kimited to the work plan dated on the front page of this application. <br />5-17-20001 M I <br />