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NWO, <br /> C" <br /> San Joaquin Coun En ironmental Health Department Unit IV Well Permit Application Supplement <br /> MACZIVYr t O pp 2 <br /> JOB ADDRESS: I �0 _ T1TT<5 :Loc"WOERMIT SR#: <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> 1 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#: _�"n –cac^7 Expiration Date: L(–,30– 2o'sp <br /> Date: Contractor: C6k3P/J3 <br /> Signature: Title: 61014 C <br /> Printed name:__ .�I►�t S O l / <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 ft <br /> by Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. <br /> e 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: J <br /> Carrier: SL1q_M &r4R[1,;.4Y�S Policy Number: 0607343– 2aO - <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'compensationrovisio of Section 3700 of the Labor Code, I shall <br /> forthwith comply with those provisions. <br /> Expiration Date: d` Signature: iy <br /> Printed Name: UV/-/,J <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 FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> is O V� —(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 /> 8-29-02 1 MI <br /> EHD 29-02-001 <br /> 6122104 <br />