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lFSan Joaquin County Environmental Health Department Unit IV Well Permit Application Supplemental <br /> jOBADDRESS: PERMIT SR# <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> I hereby affirm that I am licensed under the provisions Chapter <br /> hapt e sin full force and 9 (commencing with <br /> Section 7000) of <br /> Division 3 of the Business and Professions CddY <br /> License#: <br /> q(P(0 Z-DC7 Exp Date: 1/ 30— 2-010 <br /> s-I 2-U Q Contractor: l a <br /> Date: <br /> Title: <br /> Signature: <br /> Print Name: ^-+ <br /> WORKER'S COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the following declarations: (check one) <br /> r workers' <br /> nsation, as <br /> I have and will maintain a certificate <br /> thelaof bor Code, for thensent to insure performoance of the wokefor wh ch this <br /> provided for by section 3700 <br /> permit is issued. <br /> I have and will maintain workers' compensation insurance, as required by Section oof the <br /> Labor Code, for the performance of the work for which this permit is issued. My workers' <br /> rke <br /> compensation insurance carrier and policy numbers are: <br /> f�( C'bYvt I lS <br /> Carrier. �n�l�Policy Number: 3 <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 I should become subject to workers' compe ation provisions of Section 3700 of the <br /> Labor Code, I shall forthwith comply with those provisio <br /> Exp. Date: 5 t Signature: <br /> / <br /> Print Name: <br /> fa4� <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 OF THE LABOR CODE. <br /> UTHORIZATION"JeN-C-57 SIGNING PERMIT APPLICATION <br /> I �GIYtJ J CL(�o4signature ofC-57 licensed authorized representative), <br /> -e tohereby authorize (print name) <br /> - l��YerJ Ti/li E �i , <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 /> R1291021M1 <br /> WELL PERMIT APP <br /> El ID 29-01 11/5107 <br />