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San Joaquin County Environmental Health Department Unit IV Well Permit Application <br /> Supplement <br /> JOBADDRESS : � � � tCC1UYr� I W � � PERMIT SR# : <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 #: � �� Expiration Date: ( 1 - 30 ' � � � <br /> Date: 5 " 3 D . �toD (o Contractor: . flVlro 1�1 D {lam <br /> j Signature: Title: y T <br /> Printed name: <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 /> by 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: <br /> Carrier: % o�it17 ma , o IUISUYfte W Policy Number: I 'J 1741q - a OD 5 <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 pr visions of Section 3700 of the La or Code, I shall <br /> forthwith comply with those provisions. <br /> Expiration Date : 10 I - 2- oob Signature: r <br /> Printed Name: <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 /> ($1003000.), 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 /> I, (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 / MI <br /> EHD 29-02-001 <br /> Finina <br />