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12/ r,/2r., :: nu;:j_a y1r,Or10a� cr,nr•' F n: o <br /> FILE COPY <br /> San Joaquin County Environmental Health Department Unit IV Well Permit Application Supplement <br /> JOB ADDRESS:_/Z7 �, GfIYIVAi'� pERM1T SR#: UO / 06 <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 Proff�essi ns Codr.and my license i; in full force /an`d ffect-1 le,01 . <br /> License 0:`` ` �.� �'ExP' tion Date: ~1 _ <br /> Date:�J. Q —Contra tor: l/V--Dr�'� <br /> Signature: Title: <br /> Printed name: — <br /> WORKERS' COMPENSATI619 DECLARATION <br /> I hereby affirm under penalty of perjury one of the following declaratlons; (CHECK ONE) <br /> I have and will mnlhtain a certificate of consent to self-insure for workers'compensation,as provided for <br /> by Section 3700 of the Labor Code,for the perforiance of the work for which thin permit is issued. <br /> I have and will maintain workers' compensation insurance,as required by Section 3700 of the I.abor Code, <br /> for the performance of the work for which this permit is issued. My workers'compensation Insurance <br /> carrier anttpolicy numbe, are: <br /> carrier: �l ' G . Pollry Number:— 100 2 <br /> I certify that in the performance of the work for which this permit Is issurd, I shall not employ any person in <br /> any manner to as to become subject to the workers' compensation laws of California, and agree,that if I <br /> should become subject to the workers'compensa on provisions of Section 3700 of the Labor Code, I shall <br /> fo ihw h Comp with those prov Bions. <br /> Date: Signature: <br /> Printed Name:I <br /> WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AD SHALL SUSJFCT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> (5100,000.), IN ADDITION TO YHE COST OF COmPENSATION,INTEREST,ATTORNEY'S FEES,AND DAMAGES AS <br /> PROVIDED FOR IN SECTION 3705 OF THE LABOR CODE. <br /> THORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> I,_. .�✓l•' r` /�t.�•. .- _ si nature ofC-5 lie ed authoriaed reprc^entativa), <br /> horebyauthorize(printnamer _ G[, sc__,�I , <br /> to siiinthis San Joaquin County Will Permit Application on my bihali" I undo Land this authorization io valid for <br /> one(t)year and la limited to Elio work plan dated ort the front page of Utis application. <br /> 6-23.07./Ml <br /> 12'=16i".00:1 F'BI gE,12i1 IT1.1LY Nu 522"3 @1007 <br />