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I AtdF ni. u, <br /> Gi5-�N <br /> San Joaquin County Environmental Health Department Unit Iv Well Permit Application Supplement <br /> JOB ADDRESS: Ery �s i!}ERMI7 SR#: <br /> LICENSED CONTRACTORS DECLARATION (L.cb <br /> I hereby affirm that I am licensed under the provisions of Chapter$(commencing with Section 7000)of Division <br /> 3 of the Business and PrOffieerssigns COdr,and my license is in full force a'nId ffect. <br /> License <br /> #; I I L E�xpQpitonDato:r�1 00Date: (1 1- D —Contra tor– V�r I L <br /> —t \ <br /> signature: Title: <br /> Printed name: <br /> WORKERS' COMPENSATI6N 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-insura for workers'compensation,as provided for <br /> by Section$700 of the Labor Codo,for the performance of the work for which this 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'compenJssation insurance <br /> carrier anlpolicy numbe, are: I1 V <br /> Carrier: C� �� .—Policy Number: <br /> I certify that in the performance of the work for which this perniR Is i.ssurd, I shall not employ any person in <br /> any manner so as to 0901118 subject to the workers compensation laws of California, and agree that if I <br /> should become suhlact to the workers'compensa'on provisions of�ion 3700 of the Labor Code, I shall <br /> forthw h Co�mpp with thoso provisions. <br /> Date:_ o Signature: <br /> Printed Name: <br /> WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,A D SHALL SUBJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> (5100,000.),IN ADDITION TO THE COST OF COMPENSATION,INTEREST,ATTORNEY'S FEES,AND DAMAGES AS <br /> PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. <br /> THORIZATTION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> of nature ofc-5 lit ad authori2ed repr0^entA1iva), <br /> hareby authorize(print—name)_ - � <br /> to si!7n this San Joaquin County Woll Permit Application on my bohalf. I undo Land this authorization invalid for <br /> One(1)year and 1> limited to tho work plan dated on the front page of this applir,.atton. <br /> 8-29•(17.! <br /> [TJ,IL\ Nu SY2:3 [�%I UO2 <br />