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San Joaquin County Environmentr Aeallh Department unit M well Permit Apl,lication Supplemental <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 Section 7000) of <br /> Division 3 of eche Business and Professions Code and my license is in full force and ef+�ct <br /> License#: 4 O Exp Date: _ 1LL� <br /> Date: Contractor <br /> i 7 <br /> Signature: \ / Title. <br /> V 1 <br /> Print Name:� �T b l C�1T )—�-- <br /> WORKER'S COMPENSATPON 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 carrief and policy numbers are: <br /> Carrier: t� Policy Number: `00 <br /> 1 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' compensation provisions of Section 3700 of the <br /> Laborlg <br /> el, Ishgil forthwith comply with those provis" ns. <br /> Exp. Date: L-C I Signature: r7� Al <br /> Print Name: _Iw Y{ V 1 L-�P{ J <br /> WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,,VW SHALL SUBJECT AN EMPLOYER TO <br /> CRIMINAL PENALTIES AND CIVIL FINES UP TO S100,0W,IN AOOITION TO THE COST OF COMPENSATION,I <br /> ATTORNEY'S FEES,AND DAMAGES AS PROVIDED FOR IN SECTION 8706 OF THE LABOR CODE. NTEREST, <br /> G LIQ jJOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> C<v.. (signature of G67 licensed authorized representative), <br /> herebyauthorize prese°taLve <br /> (print name) <br /> sign this San Joaquin county Well Perm(L�p to <br /> plication on my behalf. 1 understand this authorization is valid <br /> for one year and is limited ID the work plan dated on the front page of this application. <br /> rr28g71lii <br /> =_nozaoL �L,mr <br /> WELL PEAYR APP <br />