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03/202006 18:42 GEOMRTR1 -RAWHO CORDOOR - 15306682429 NO.144 002 <br /> San Joaquin County Environmental Health Department Unit IV Well Permit Application Supplement <br /> JOB ADDRESS: PERMIT SR#: <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> I hereby affirm that I am licensed under the provisions of Chapter 9(commencing with Seclion 7000)of Division <br /> 3 of the Business and Professions Code and my license is in full force and effect. <br /> License IY Z 3 3 Expiratlon Data <br /> Date; 3 2i v Contractor j�savJn^rS�ti d <br /> Signature._ r— Title: <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 /> ,LCI have and will maintain workers'compensation insurance.as required by Section 3700 of the Law Code, <br /> for the pedodmance of the.work for which this permit is issued. My workers'compensation insurance <br /> Carrier and policy numbers are: <br /> Cartier. S4-- r-, ate( Pollcy Number. <br /> 1 certify that in the performance of the work for which this permit is issued. 1 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 those provisions. <br /> Expiration Date: d 2 a� Signature:' '_. <br /> Primed <br /> WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINE8 UP TO ONE HUNDRED THOUSAND DOLLARS <br /> (1100,000.),IN ADDITION TO THE COST OF COMPENSATION,INTEREST,ATTORNEY'S FEES,AND DAMAGES AS <br /> PROVIDED FOR IN SECTION 3701 OF THE LABOR CODE. <br /> AUTHORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> 1, R...� {algnature DIC-67 licensed authorized representative). <br /> hereby authorise{print name) r 440WA fe M, <br /> to sign this San Joaquin County Well Permit Application an my behalf. I understand 04a authorization is valid for <br /> one(1)year am Is limited to the work plan dated an the front page of this application. <br /> a-�-09/tip <br /> EFID 7942-W i <br /> 62710/ <br /> a -d 6Zi+Z-699 ( 069) SIU1111.1lI ISH eZy =OT 90 To .JeW <br />