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San Joaquin County Environm al Health nDartment Unit IVWell P0it Applicationn Supplement <br /> JOB ADDRESS: l� PERMIT SR#:/®7)0 bZ <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/ <br /> and Professions Code and my license is in full force and effect. / <br /> License #: �01� ��� Expiration Date: _i U!! SSI �I 1 c�Off <br /> Date: I ) ' I�-07 C ractor: <br /> Signature: n Title: Lone •M�InF s�CIT <br /> Printed name: �\C\ QeCk <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: f G / <br /> Carrier: nc\rs '1 Policy Number: \'v C o�L2(O S 15,/ <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 tho provisions. <br /> Expiration Date: It Signature: <br /> F I Do Printed Name: (.)\C.\ <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 /> � <br /> AtltlA/UTHORIZ"ATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> I, (-CI �rN p_ '' (signature ofC-57 licensed authorized representative), <br /> hereby authorize (print name) Niki . <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 /> B-29-02 / MI <br /> EHD 29-02-001 <br /> 6/22/04 <br />