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San Joacmwcounty Environmental He h Department Unit IV Well Permit Application Supplement <br /> JOB ADDRESS: ')Of <br /> -r-r" ` L" PERMIT SR#: 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 Professions Code and my license is in full force and effect. <br /> License#: 7 1 7 S 10 Expiration Date: 11 S)1 a y <br /> Date: 7— a- ) — D 3 C ntractor: ems"-OC Off-'a wS ,tom <br /> Signature: k I Title: 7Q2/Gt nS / (anav?er <br /> Printed name: y C a 12"7 Cr r'� <br /> WORKERS' COMPENSATION 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-insure for workers' compensation, as provided for <br /> by Section 3700 of the Labor Code, 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 Labor Code, <br /> for the performance of the work for which this permit is issued. My workers' compensation insurance <br /> carrier andel policy numbers are: 1 7 <br /> Carrier: 11 l asI40. /V 0 � 0n a/ Policy Number: U� Ew s�05 3 <br /> I certify that in the performance of the work for which this permit is issued, 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' compensation provisions of Section 3700 of the Labor Code, I shall <br /> forthwith comply with those provisions. <br /> Date: 7"a Signature: I <br /> Printed Name:_v C✓a /1 rc ✓/ Yt Q <br /> WARNING: FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> ($100,000.), 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 /> AUT I TION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> I, L (signature ofC-57 licensed authorized representative), <br /> hereby authorize rint name)` '- ^ ti Pn^sco-� SZ's-c ^''it`"''°°s'v'""� k^' <br /> to sign this San Joaquin County Well Permit Application on my behalf. I understand this authorization is valid for <br /> one(1)year and is limited to the work plan dated on the front page of this application. <br /> 6-29-021 MI <br />