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— - - 7) <br /> 1DP <br /> San Joaquin County Environmental Health De artment Unit IV Well Permit Appli ation Supplemental <br /> JOB ADDRESS: ' MIT SR . ��� <br /> C�Pr N 5 7� <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> I hereby affirm that I aryl licensed under the:provisions of Chapter 9 (commencing with Section 7000)of <br /> Division 3 of the Business and professions Code and my license is in full force and effect. <br /> License to - $ _. Exr, Date: , <br /> I W I n <br /> Date: � � Contractor. ez4 S I CW t. & 1 L <br /> Signature: i Title: <br /> Print Name: ,3 FfJ�I rly_1 tlFDl�1 <br /> WORKER'S COMPENSATION DECLARATION � <br /> I hereby affirm under penalty of perjury'one of the following declarations:(check one) i <br /> I have and will maintain a certificate of consent to self insure for workers'compensation, as <br /> prodded 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 Cade, for the performance of the work for which this permit is issued. My workers' <br /> compensation insurance carrier and policy numbers are: <br /> AtME6zl CArJ 1 NTE3¢,iN�} Ortill L <br /> Carrier::5eM g , tyrJ & _Policy Number <br /> t N5Uern.►5- CXtAm-sit <br /> I certify that in the performance of the work for which t is pefirri t is issued, I shall not employ any <br /> person in any manner so as to become subject to the orkers'compensation law of Cafifornla, and <br /> agree that if I should become subject to workers'comlensaflon provisions of Section 3700 of the <br /> Labor Code, I shall forthwith comply with those pro isi ns. <br /> Exp. Date:T fe,j,1,2X00_1 Signature: <br /> Print Name. 1 46-. 4Z010Lh <br /> WARNING:FAILURE TO SECURE WORKERS COMPENSAMN COVERAGE IS NLAWFUL,AND SHALL SU13JECT AN EMPLOYER TO <br /> GRiMINAL.PENALTIES AND CIVIL FINE$UP TO$100,000,IN ADDIT ONTO THE COST OF COMPENSATION.INTEREST, <br /> ATTORNEY'S FEES,AND DAMAGES AS PROVIDED FOR IN SECTIC N 3706 OF THE L48OR CODE. <br /> '-�IITM NZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> i (signatu f C licensed.auth rued representative), <br /> hereby authorize(print name) i � 1\ � ! � ,to <br /> sign this San Joaquin county Well Permit Application on my behalf. I understand this authorization is valid <br /> ;or one year and is limited to the work plan dated on the front page of this application. <br /> ;arzV02M <br />