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San Joaquin County Environ al Health D artment Unit IV Well Pit Application Supplement <br /> JOB ADDRESS: l� 7 `M PERMIT SR#:/ 053 D� D <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> I hereby affirm that I am licensed 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 #: (ciL Y ,Z� Expiration Date: _'-I U/ )U,j -1 Ca� <br /> Date: I) ` C ractor: <br /> Signature: np nn Title: <br /> Zane (vM(vvc,$)or <br /> Printed name: l\c / ! \ QQ C <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, 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 /> �61-L2U s <br /> Carrier: MhC5\-N tiIC( <br /> 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 /> 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' compensation provisions of Section 3700 of the Labor Code, I shall <br /> forthwith comply with thos provisions. <br /> Expiration Date: 11 p0-7 Signature: <br /> Printed Name: ONU <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 /> ($100,000.), 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 OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> Aq / ('- yr.p (signature ofC-57 licensed authorized representative), <br /> hereby authorize (print name) 404*g-,, Sjp-�— <br /> to sign this San Joaquin County Well Permit Application on my behalf. I 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 /MI <br /> EHD 29-02-001 <br /> 6/22/04 <br />