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San Joaquin County Environmental Health Department Unit IV Well Permit Application lenient <br /> JOB ADDRESS: 6421 Capitol Ave. , Lodi CA 95245 PERMIT SR#• S 9 - <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#. 1 I 7 `5 10 Expiration Date' � l J � — 10 n <br /> Date. `">" — 2-2�-Gq) Contractor.CCkS G � G <br /> Signature: 11 <br /> Printed name: V M I 11 o <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 self41nsure 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 /> V/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 an/d�policy numbers are: �J t/�1 I r 2 <br /> Carrier. I"1 YLS r`-"" a�( ��" ` Policy Number: <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 3760 of the Labor Code, I shall <br /> forthwith comply with those provisions. <br /> Expiration Date: lI —V t Signature: I <br /> Printed Name: 0 V1 rA V-01-AA I I t O - <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 /> P <br /> SROVIDED IN IN SECTION 37 8 O <br /> ADDITION OF THE LABOR CODEION,INTEREST,ATTORNEY'S FEES,AND DAMAGES AS <br /> AUT RIZAMON FOR OTHER THAN C-67 SIGNING PERMIT APPLICATION <br /> (signature ofC-67 licensed authorized representative), <br /> hereby authorize(Print name) T1 mD�i crrer, aacrrm. *n — <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 /> 8-29-021 MI <br /> EH D 2902-001 <br /> 6.72104 <br />