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. uoz <br /> 1�;1E,/11:r`7:; f]J:ay 516:1G10� �,ru it • I 'AkiF ii. 0, <br /> San Joaquin County EnvfrOtimeatal Health Department Unit IV Well Permit Application Supplement <br /> JOB ADDRESS: PERMIT PERMIT SR#: ©O 5leD <br /> LICENSED CONTRACTORS DECLARATION (LCD <br /> I hereby affirm that I am licensed under the provisions of Chapter y(commencing with Section 7000) of Division <br /> 3 of the Business and Professi ns CDdn and my license is in full force /an1Jd ffect. <br /> License#:I . ILEl�xp�Q��tion Gate: <br /> Date:�1- Q _Contra'tcr: <br /> 1 \ <br /> Signature: 1 ( Title: <br /> Printed name: — <br /> WORKERS' COMPENSATI( I DECLARATION <br /> I hereby affirm under penalty of perjury one of the following declarations: (CHECK ONE) <br /> I have and will maintain a cort'rffcate of consent to self-insure for workers'compensation,as provided for <br /> by Section 3700 of the Labor Code,for the perfomiance of the Work for which thiz pormit 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 anti policy numbe, ure: <br /> Carrier: Pollry Number: V I <br /> I certify that in the performance of the work for which this permit Is i.ssurd, I shall not employ any person in <br /> any manner so 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�ion 3700 of the Labor Code, I shall <br /> forthw' h Comp with those provisions. <br /> Date: Signature: <br /> Printed Name:' . r <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 /> (STDO,DOO.),IN ADDITION TO THE COST OF COMPENSATION,INTEREST,ATTORNEY'S FEES,ANO DAMAGES AS <br /> PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. - <br /> 7HORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> of hatum ofC-5 lit ad authorized reprecen4ativa), <br /> —` <br /> hare6y authorize(print name) <br /> to sign this San Joaquin County Woil Permit Application on my bohalf. I Ugde tantl Ntis authorizadan is valid for <br /> one(1)year and Is limited to thu work plan dated on the front page of this application. <br /> B•23.07./MI <br /> IY'26i^.00:1 FRI 0£1-20 V1007. _ <br />