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San Joaquin County Environmental Health Department Unit IV Well Permit Application Supplement <br /> JOB ADDRESS: �yya W. 9RNNG2 AV Z, PERMIT SR#:�� Z <br /> 9 5?- f <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 BusinessandProfessions Code and my license is in full force and effect. L <br /> License#: 6U O Z Z //�� Expiration Date: rNO V Pnn h Z e a <br /> Date: Contractor: IiJVANc ' SFa `Cdlti Qe?mpA1/Q l -�✓I� <br /> Signature: T qq Title: f <br /> Printed name: 11ma !q+, - <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the following declarations: (CHECK ALL THAT APPLY) <br /> _I have and will maintain a certificate of consent to self-insure for workers' compensation, as provided for by <br /> 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 /> t for the performance of the work for which this permit is issued. My workers' compensation insurance <br /> carrier and policy numbers are: q <br /> 5T�A76 cpMp�nx�ion 22 —7\, � , ZDo <br /> Carrier: �vl NGQ FvNO Policy Number: 7 117 7V� <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, 1 shall <br /> forthwith comply with those provisions. <br /> Date: 9ISignature: 1 <br /> Printed Name: 41 An e ri� i <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 /> (signature ofC-57 licensed authorized representative), <br /> hereby authorize (print name) <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 /> 1-25-02/MI <br />