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i - <br /> .86/I4/2884 09:07 2894593433 FIFTH FLOOP <br /> i <br /> San Joaquin County Environmental Health Department Unit IV,Well Permit Application Supplement <br /> JOB ADDRESS: PERMIT SR#: <br /> LICENSED CONTRACTORS DECLARATION (L_ CD) <br /># 1 hereby affirm that I am 11censed 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 /> License , �� __L Expiration Date: ` <br /> Date: Contractor; <br /> Signature: Title: <br /> Printed name.• <br /> WO KERS' COMPENSATION DE=CLARATION <br />{, I hereby affirm under penalty of perjury one of the following declara%, ns: (CHECK ONE) <br /> I have and will maintain a certificate of Consent to self insure for workers'compensation,as provided for <br /> i 3 �by Section 3700 of thea Labor Code,for the performance of the work for which this permit is issued, <br /> xi have and will maintain workars'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: hy / S Policy Number: <br /> I certify that in the performance of the work for which this permit is issued, I shall not employ any person in <br /> arty manner so as to become subject to the workers'compensation laws of California, and agree that if I <br /> should became subject to the workers'compensation provisions of Section 3700 of the Labor Code, I sham <br /> forthwith comply with those provisions. <br /> Expiration Date: / ds Signature: <br /> Printed Name- 1 1 1 <br /> WARNING:FAILURE TO SECURE VVORKERS'COMPENSATION COVERAGE 15 UNLAWFUL.AND SMALL SUBJECT <br /> AN EMPLOYER To CRIMINAL PENALTIES AND CIVIL.FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> {$1110,000.1,IN AaDMON TO THE COST OF COMPENSATION,INTEREST,ATTORNEY'S FEES,AND DAMAGES A5 <br /> PROVIDED FOR IN SEcTiUN 3706 OF THE LABOR CODE. <br /> AUTHORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> I, (signature afC-57liceJnsed authorized representative), <br /> hereby authorize(print name <br /> to sign this San Joaquin County WeII Permit Ap catlo n 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 /> 8-29-02 r M <br /> EI{D 2P-42.401 <br /> - 9/3Ur�OQ3 <br /> D M c r .. _.,.... 1 <br /> SCI CT ! CCTCC 7C "'"T <br />