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0 0 <br /> San Joaquin County Environmental Health Department Unit IV Well Permit Application Supplemental <br /> JOB ADDRESS: ( ' , -� PERMIT SR # <br /> py,—t p V)A , C l(—C <br /> LICENSED CONTRACTORS DECLARATION <br /> (LCD) <br /> I hereby affirm that I am licensed under the provisions of Chapter 9 (commencing with Section 7000) of <br /> Division 3 of the Business and Professions Code and my license is in full force and a ct. <br /> Licensle ` i 0 Exp Date: I 1 <br /> Date: � � Contractor: LY t �� ' <br /> SignaTitle: �- --- <br /> Print Name: � �-�- VI <br /> ' o.-V' <br /> c <br /> WORKER'S COMPENSA N 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 <br /> provided for by section 3700 of the labor Code, for the performance of the work for which this <br /> permit is issued. <br /> I have and will maintain workers' compensation insurance, as required by Section 3700 of the <br /> Labor Code, for the performance of the work for which this permit is issued. My workers' <br /> compensation insurance carne and policy numbers are: <br /> Carrier: %* Fu-n Poticy Number: <br /> lam' <br /> I certify that in the performance of the work for which this permit is issued, I shall not employ any <br /> person in any manner so as to become subject to the workers'compensation law of California, and <br /> agree that if l should become subject to workers' compensation provisions of Section 3700 of the <br /> Labor 9de, 1 spall forthwith comply with those provis' ns. <br /> � Z <br /> j Exp. Date: 1 Signature: <br /> Print Name: <br /> WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT AN EMPLOYER TO <br /> CRIMINAL PENALTIES AND CIVIL FINES UP TO$100,000,IN ADDITION TO THE COST OF COMPENSATION,INTEREST, <br /> ATTORNEY'S FEES,AND DAMAGES AS PROVIDED FOR IN SECTION 3706 TH THE LABOR CODE. <br /> T O . I R OTHER THAN C.57 SIGNING PERMIT APPLICATION <br /> I' (signature of C-67 licensed authorized representative), <br /> hereby authorize(print name) _�_ ,D G4 C, , I V\-g . <br /> ,to <br /> sign this San Joaquin county Well Permit Application on my behalf. I understand this authorization is valid <br /> for one year and is limited to the work plan dated on the front page of this application. <br /> arzsro�null <br /> _I+u <br /> 29.01 1115M7 <br /> WELL PERMIT APP <br />