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N Pj� ° � � <br /> San Joaquin Gounfy E-rivironmental Health DeparlynGnt Untt [S Well PererEttlappd6eatlon Suppferrierit <br /> JOB ADDRESS :�Z9a-_ _. ',� C�=y)� . 5 �- PERMIT sly: DD 17`� <br /> i Gk <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 #: - -5 l=td- 6 7 Z b 17 Expiration Date: ��0 7 <br /> Date: ( ( 7 Z (7 Contractor: N I 1 G tt y! :L pI /tn�t ,� <br /> Signature: <br /> ��— Title: y r <br /> Printed name: G Z- U (z 6 �,, <br /> WORKERS' COMPENSATION DECLARATION <br /> 1 hereby affirm under penalty of perjury one of the following declarations: (CHECK ONE) <br /> I have and will maintain a certificate of consent to sell-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 /> 1 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 and policy numbers are: <br /> Fo£� Et1C _ PJ6 � Gy ... Polis Number, 2 <br /> Carrier: u � y <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 . j <br /> Expiration late: 7 <br /> G G} 1 Signature: <br /> Printed Name: <br /> WARNiNo. 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 /> (S7lte1000.), IN ADDITION TO THE. COST OF COMPENSATION, INTEREST, ATTORNEY'S FEES. AND DAMAGES AS <br /> PROVIDED FOR IN SECTION 3798 OF THE LABOR CODE, <br /> AUTHORIZATION FOR (7TI4ffR THAN C47 SIGNING PERMIT APPLICATION <br /> Imo- (signature ofC47licensed authorized representative), <br /> hereby authorize (printnante) � U �✓d - <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 datod an the front page of this application- <br /> 849-V2 f MI <br /> EHo 294)2-001 <br /> 4M,IAA <br />