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1�i_'E/2pRa l :a'd 160GU?• G�GrIR A6F f1:', 0'6 <br /> San Joaquin County Environmental Health Department Unit IV Well Permit Application SUpplament <br /> JOB ADD RES PERMIT SRMA) 5:5,1 <br /> LICENSED CONTRACTORS DECLARATION (LCB <br /> I hereby affirm that I am licensed under the provisions of Chapter g(commencing wlth Section 7000)of Division <br /> 3 of the Business and Pro'rf�e7ssi ns Codr.and my license is in full force and ffect. <br /> License#: I"L4 'Elxp'.tio�n Date`; �l.X <br /> Date:�� D _Contra tor: i/��� 1 <br /> 1 \ <br /> Signature: Title: . <br /> Printed name: C) j '_ C <br /> WORKERS' COMPENSATIt3NN DECLARATION <br /> I hereby affirm under penalty of perjury one of the following declaratlons; (CHECK ONE) <br /> I have and will maintain a certficate of consent to self-insure for workers'compensation,as provided for <br /> by Section 3700 of the Labor Cado,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'componsatinn Insuranec <br /> carrier 2 .ngpolicy nurnbe nre: <br /> Carrier: C Polley Number: l I VL I i� <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 so as to become subject to the workers componsation laws of California, and agree that if I <br /> should become subject to the workers'oornpensa'on provisions of Section 3700 of the tabor Code, I shall <br /> forthw' h oompW with those provisions. <br /> Date: those provisions <br /> Printed <br /> WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AD SHALL SUBJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> (S100.000.), IN ADDITION TO THE COST OF COMPENSATION,INTEREST,ATTORNEY'S FEES,AHD DAMAGES AS <br /> PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. - <br /> 7, HORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> 1 <br /> � r'" .C..�� m"natumofc;-S lie edauthoriaed reprrsentativa], <br /> horebyauftrize(printnama)TL <br /> n thioSan Joaquin County Woll Permit Application on myland this au✓✓thorization is wilid for <br /> 1)yearand Is Ilmited to tho work plan dated on the front page of this applleadon. <br /> Ml <br /> t2/1'0111.005 Fi'.I (11, '20 [Tx'IL\ No 5222] [x!002 <br />