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WORKERS' COMPENSATION DECLARATION <br />I hereby affirm under penalty of perjury one of the following cle.;,faretions: (CHECK ALL THAT APPLY) <br />I haVe and will maintain a pertificata of consent to self-insure for workers' compensation, as provided far by <br />Section 3700 of he labor Code, for the performance af the work for which this permit is issued. <br />`4, have and will maintain workers' compensation insurance, as required by eclion 3700 of the Labor Code, <br />for the performance of the work for which this pen-nit is issued. My workers' compensation insurance <br />carrier and policy numbers are: <br />F-1't Aid <br />I certify that in the performance of tne work for whicb this permit is issued, I shall not employ any person in <br />any marme,r so as to become subject to the workers' compenceloO laws of California, end agree that if <br />should become subject to the workers' compensation provisions of Section 3700 of the Labor Code, shalt <br />forthwith comply with those provlsionS. <br />Date; Signature: <br />Printed Name; <br />'NARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAOE IS UNLAWFUL AND SHALL SUELIECT <br />AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br />1100,0004, IN ADDITION TO THE COST OF COMPENSATION, INTEREST, ATTORNEY'S FEES, AND DAMAGES AS <br />PROVIDED FOR IN SECTION 37060F THE LABOR CODE <br />114 (c-de--i • (C-57 licensed authorized representative), henay <br />f ) 4(A-1 I) 0 tdo i1/4) tvjA fL_EtiViran /— authorize <br />to sign this San Joauvin County Welt Permit Arniilcstlon on my behalf. understand this authorization is yed <br />one ft) year and Is limited to the work plan datod on tho front page of thls apptIcation, <br />1 <br />5.i17-2000 MI <br />Carrier- Policy Number 1,5-8 L In la, LI " <br />ORIGINAL <br />San Joaquin County Environmental Health SorvIcas, Unit 11/ Well Permit Application Supplement ' <br />JOB ADDRESS: PERMIT <br />LICENSED CONTRACTORS DECLARATION (LCD) <br />I hereby affirm that I am ficanseti under the provisions at Chapter 9 (cOMMenCing with Seam 7000) of Divislan <br />3 of the Business and Professions Code and my !leen= is in full force and effect. <br />• <br />Date: <br />Signature: <br />Printed name: <br />Contractor: <br />.:(piration Date: CA ---_3 0 — 0 3 <br />/14/ <br />Title: L./t/j <br />II :Tx, <br />License #: <br />6RIctu;26/7`fic-