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r <br /> San Joaquin County Environmental Health Department Unit IV Well Permit Application Supplement <br /> J013 ADDRESS: 1"138 , SA57 A -Pit�E .A�Q6 PERMIT SR#: <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> I hereby affirm that I am Ilmnsed 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 Expiration Date:, L/_3�, 2ooFf <br /> Date: Ccntractor: "1 Ytv q L <br /> Signature: Title: <br /> Printed name: _ ,J,,Jr S <br /> WORKERS' 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 provided for <br /> by 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,az required by Section 3700 of the Labor Code, <br /> the performance of tha work for which this permit is issued. My workers'compensation Insurance <br /> carrier and policy numbers are: <br /> Carrier: palicy Numbers Oo c> 7 5('3 — 2"ob <br /> I certify that in the performance of the work for which this permit is issued, 1 shall not employ any person In <br /> any manner so as to become subject to the workers'compensation laws of California, and agree that If I <br /> should become subject to the workers'compensat�provlsigns of Section 3700 of the Labor Code, I shall <br /> forthwith Comply with those provitions. <br /> Expiration Date: /O 7 z 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 /> (5100,000.),IN ADDITION TO THE COST OF COMPENSATION.INTEREST,ATTORNEY'S FEES,AND DAMAGES As <br /> PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. <br /> AUTHORIZATION FOR 077ff THAN C-57 SIGNING PERMIT APPLICATION <br /> (signature ofC-67 licensed authorized representative), <br /> i t E L c bY�>^�+k C t1Z 0 Y T6Ac0 tom) <br /> hereby authorize(print Hama) <br /> to sign this San Joaquin County Well Permit Application on my behalf. I understand this authorization if valid for <br /> one(1)year and Is limited to the work plan dated on this from{rage of this application. <br /> 029-02 f MI <br /> ENI]29.02.001 <br /> 6/RLo4 <br />