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1 i .,,G, LICENSED CONTRACTORS DECLARATION (LCD) <br />LOB _ V\1154\1 62-1 gfr <br />San Joaquin County Environmental Health-Serlices, WIRD/ Well Permit Application-Supplement <br />ADDRESS: 1.---/-01 V\401- PERMIT SR*: 0 <br /> <br />I hereby affirm that I am licensed under the provisions of Chapter 9 (commencing with Section 7000) of Divdo <br />3 of the Business arid Professiors Code arid my bcense is in full force and effect <br />License #: Expiration Date: l'a7C) <br />Date: 10 • Z(g • Contractor: -Fir,,k100 )4t-, 1J_. <br />Signature: <br />Pointed name: W*kc <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 sehf-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 />I 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 arid policy numbers are: <br />Canion f60:7 Policy Number: /S4- <br />I certify that in the performance of the work for which this pemit is .issued, I shall nct employ any person in <br />any manner so as to become subject to the workers' compensation laws of CaPfornia. and agree that if I <br />should become subject to the workers' compensation provisions of Section 3700 of the Labor Cade, I shall <br />forthwith comply with those provisions. <br />X/ Date: I D ZG7 • signature: <br />Printed Name: <br />WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT <br />AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br />($100,000.), IN ADDITION TO THE COST OF COMPENSATION, INTEREST, ATTORNEY'S r+-k-b, AND DAMAGES AS <br />PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. <br />1.1‘..3(71‹_ <br /> <br />(C-57 licensed authorized representative), hereby <br /> <br />authorize 9.1?-11- t\A \9'fi<1.1 <br />to sign this San .1oaciuin County Well Permit Application on my behalf. I understand this aisthonzation is valid for <br />one (1) year and Is Ilrnitad to the Ivor* plan dated on the front page of this application. <br />OCT-27-1999 1029 FROM PRECISION SAMPLING TO 12094683433 P.02 <br />TOTAL P.02