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[ San Joaquin County Environmental Health Services, Unit IV Well Permit Application Supplement <br /> JOB ADDRESS: /0,3 S. PERMIT SR#: <br /> LICENSED CONTRACTORS ECLARATION (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#: Cs 7 7 7 S Q Expiration Date: --3( r Q— <br /> g— —d I Contractor: CrSC_Ct n _fi C <br /> Date: ,M <br /> Signature: Title: e � i..vr� , {��Q ►� <br /> Printed name: t C <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the following eclarations: (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 o 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: / <br /> Carrier: A l CZ S ka �-I, . Policy Number:„ 0 4L_W5 -' O's , <br /> I certify that in the performance of the work for which t is 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 /> ii <br /> should become subject to the workers' compensation pro 0 of Section 3700 of the Labor Code, 1 shall <br /> forthwith comply with those provisions. <br /> Date: Signature: <br /> Printed Name:Aze <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 /> IN ADDITION CT ON 37E COST <br /> OFTHE OF C OR NSATIO , INTEREST,ATTORNEY'S FEES,AND DAMAGES AS <br /> PROVIDEDFORINCODE <br /> I, X0A arm (C-57 licensed authorized representative), hereby <br /> e,nea <br /> 1-21 <br /> authorize '� V,e_ le r 2-0 <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 />