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San Joaquin County EnvironmIntal Health Department Unit IV Well Permit Application Supplemental <br /> JOB ADDRESS: q3 l- PERMITSR# <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> I hereby affirm that I am licensed under the provisions of Chapter 9(commencing with Section 7000)of <br /> Division 3 of theme�Business and Professions Code and my license is in full force and effect. <br /> License* <br /> )q- : -4 73- Exp Date: 6" <br /> Date.- Contractor: g 2ga-, <br /> Signature: Title: <br /> Print Narne: beVA;;6 f"T,-1-_ <br /> COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the following declarations:(check one) <br /> I have and will maintain a certificate of consent to self-insure for workers'compensation, as <br /> provided for by section 3700 of the labor Code,for the performance of the work for which this <br /> permit is issued. <br /> I have and will maintain workers'compensation insurance,as required by Section 3700 of the <br /> Labor Code,for the performance of the work for which this permit is issued. My workers' <br /> compensation insurance Carrier and policy numbers are: 343 <br /> Carrier:,- .-FIUA3. ef)+Policy Number: oonl/3'13Cco <br /> I certify that in the performance of the work for which this permit is issued, I shall not employ any <br /> person in any manner so as to become subject to the workers'compensation law of California, and <br /> agree that if I should become subject to workers'compensation provisions of Section 3700 of the <br /> Labor Code, I shall forthwith comply with those provisions <br /> Exp.Date.-_, Signature: <br /> Print Name: 41"vIlAJiJ <br /> WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT AN EMPLOYER TO <br /> CRIMINAL PENALTIES AND CIVIL FINES UP TO$100,000,IN ADDITION TO THE COST OF COMPENSATION,INTEREST, <br /> ATTORNEYS FEES,AND DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. <br /> -57 SIGNING PERMIT APPLICATION <br /> ,JJT,H,QRINEON FOR,_ THAN C <br /> Sig ature of C-57 licensed authorized representative), <br /> hereby authorize(print name) -3- ,to <br /> sign this San Joaquin county Well Permit Application on my behalf. I understand this authorization is valid <br /> for one year and is limited to the work plan dated on the front page of this application. <br /> 8129102M <br /> END 2961 IIJ5107 WSLL PEWAIT APP <br />