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10/03/2003 FRI 1:4:00 FAX <br />E1002 <br />San Joaquin County Environmental Health Services, Llnit•IV Wer.11..Permit.Apcation <br />Siippiatnent <br />JOB ADDRESS:6, IJ . PERIMIff SRg <br />LICENSED CONTRACTORS DECLARATION (LCD) <br />I hereby affirm that I <br />am licensed under the proyisions of Chapter 9 <br />(commencing with Section 7000) of Division <br />3 of the Business and Professions Code and my license is in full force arid effect. <br /> <br />Expiration Date: • <br />_11')C • <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 />— <br />V I have and will maintain workcrs' compensation insurance, as required by Section 3700 of the Labor Code, <br />Date: 0 .5 I31,3 Signature: <br />, <br />Carrier: EtAl. <br />Section 3700 . <br />ot the Labor Code, for the performance of the work for which this permit is issued. <br />for the performance of the work for which this permit is issued. My workers' compensation insurance <br />carrier and policy numbers are: <br />I certify 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 laws of California, and agree <br />. that It I <br />should become subject to the workers' compensation provisions of Section 3700 of the Labor Code, I shall <br />forthwith c mp y with hose provisions, <br /> <br />Polley Number: <br />A. <br /> ) <br />_A <br />ended authorized representative), hereby <br />I,.1. OP <br />1111712211111101 <br />authorize <br />to sign this San Joaquin County Well Perrnit Application on my behalf. I <br />understand thls authorlzation is valid for <br />one (1) year and is limited to the work plan dated on the front p_21.)f this al 3 t <br />License#: rid <br />Date: <br />Signature: 4161 <br />/t <br />Printed name: \1/4._.A4_74 <br />ontractor: <br />P tinted Name: <br />WARNING; FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL SUBJECT <br />, .., <br />AN VOIPLOYER <br />TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br />($100,000 <br />.), IN ADDITION TO THE COST OF COMPENSATION, INTEREST, ATTORNEY'S FEES, <br />AND DAMAGES AS <br />PROVIDED FOR IN SSCTiON ans OF THE LABOR CODE. <br />1,4\7-175; EiEG 17 VO—Cf) I