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San Joaquin County Environmental Nealth Department Unit IV Well Permit Application Supplement <br /> JOB ADDRESS- D�BF, r;�yil I?1.C ytpERM(T 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 fu 11 force and acl e <br /> License tl: i0-I CIEmirationData: 'l j I� CDate: Co ra or. D Vi� 1 r) <br /> Si <br /> gnature: HiYt. (�� , r rill®: , <br /> Prhtted 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 aelf-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 <br /> �numbers are: )1 <br /> Carrier. "J J 1ZI r ^Policy Number. <br /> I certify that in the performance of the work for which this perms 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 1 <br /> should become subject to the workers'compensation provisions of Section 3700 of the Labor Cate, I shall <br /> forthwith comply with those provisions. i; r <br /> Expiration Date: signature: j�,� <br /> Printed Name: E. <br /> WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWF AND SHALL SUBJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> ($700,000.),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 /> (signature 0fC-S7 ficonsed authorized representative), <br /> hereby authorize(print name) SS <br /> to sign thlc San Joaquin County Well Permit Application on my behalf. I understand this authorisation is valid for <br /> i <br /> [one(f)year and Is limited to the work plan dated on the front page of this application. <br /> 8-29-02 f MI <br /> Ef11129d13-W] <br /> 9/30/21002 <br />