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Now A4ctz <br /> L <br /> San Joaquin Cour ; r=r^. ;.: : ftal health Department Unit IV Well Permit Application Supplement <br /> JOB ADDRESS: �tf' ERMIT SR# 0 <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> I hereby affirm that I am licensed under the provisions of Chapter S (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 Expiration Date: Y 3y� 2tW Y <br /> Date: Contractor: Cik-1P/=S <br /> Signature._ Title: � <br /> Printed name: >,VAS i) 4 / / <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 /> Eby 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 and policy numbers are: Q <br /> Carrier: A� <br /> S oi�l .: I .j v`srcJr�cl <br /> ,. .� _ Policy Number: 000 '7,763— Zaca S— <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�provisio of Section 3700 of the Labor Code, I shall <br /> forthwith comply with those provisions. /1 <br /> Expiration Date: i O` b 1 Signature: �G / <br /> JW <br /> Printed Name: �v %� 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 /> ($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 /> AUTHORIZATION F=sIgnature <br /> 7 SIGNING PERMIT APPLICATION <br /> 1 "�^' O 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 /> 8-29-021 MI <br /> E14D 29-02-001 <br /> 6/22/04 <br />