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San Joaquin County Environ al Health D artmevt Unit IV Well Pffflt Application Supplement <br /> JOB ADDRESS: /6 � y PERMIT SR#:/ 0s 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 Prro�fessions Code and my license is in full force and effect. <br /> License#: WI� Y (� Expiration Date: .1-Iu�JS� 2J 1 06X' <br /> Date: 11 — �}—O7 C ractor: (joc k Lon eg� <br /> Signature: pp n Title: Zone MCknF9er <br /> Printed name: Ko, \` QQCE <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 andn( Wppolicy numbers are: ` t r <br /> Carrier: 1� c\(5'n Policy Number: C( C[ <br /> 1AID 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: �aI p0-7 Signature: ` c1 <br /> a �o Printed Name: ()\a <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 /> Ir-1 Zpprp (signature ofC-57 licensed authorized representative), <br /> hereby authorize (print name) 44t,, Si ` <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 />