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209-234-0538 Llne1 0 0:57 11-28-2007 2'2 <br /> San Joaquin County Environmental Health Department Unit IV Well Permit Application Supplement <br /> JOB ADDRESS: lo.I 5' t R4,0' J� PERMIT SR#: <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 efect. <br /> License#: U� n Expira/tiioon Date: <br /> Date: t;i- on <br /> Slgnatu Title: V <br /> Printed name: <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 /> Carrier.2 I-I,IAd Policy Number: —7/5 `/ FSS 3-7- dC-- <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'compe a rovisions of section 3700 of the Labor Code. I shall <br /> forthwith comply with those provisions. <br /> Expiration Date:° D7 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 /> ($100,000.),IN ADDITION TO THE COST OF COMPENSATION,INTEREST,ATTORNEY'S FEES,AND DAMAGES AS <br /> PROV NSE 10 6 OF THE LABOR CODE. <br /> AUTH RIZATION F R 6 R THAN C-57 SIGNING PERMIT APPLICATION <br /> signature�ensed authorized representative), <br /> hereby authorize(print name) <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 /> fitip),9-02.001 <br />