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San Joaquln(�Dunty Envir nmentai Health partment Unit w Well Permit Application Supplemental <br /> JOB ADDRESS: ``'' / <br /> PERMIT SR# V <br /> LICENSE CONTRACTORS DECLARATION (LCD) <br /> I hereby affirm that I am licensE d under the provisions of Chapter 9 (commencing with Section 7000) of <br /> Division 3 of the Business and Professions Code and my license is in full force and a ct. <br /> License#:, tt a o q C) Exp Date: <br /> h / <br /> Date:LL L Contractor L� )Yt vi V- <br /> Signature: L Title: <br /> Print Name: V1 <br /> VYORKER'SCOMPENSATION 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 <br /> provided for by section 3700 of the labor Code, for the performance of the work for which this <br /> permit is issued. <br /> I have and will maintain workers' compensafion insurance, as required by Section 3700 of the <br /> Labor Code, for the per nuance of the work for which this permit is issued. My workers' <br /> compensation insuran Carrie and policy numbers are: <br /> Carrier. Policy Number: `U l J� <br /> I certify that in the performance of the work for which this permit is issued, i shall not employ any <br /> person in any manners as to become subject to the workers' compensation law of California, and <br /> agree that if I should b me subject to workers' Compensation provisions of Section 3700 of the <br /> Labor C e, I `sh II forthwith comply with those provis. ns. !� <br /> Exp. Date: �, ` Signature: <br /> Print Name: V I L <br /> WARNING:FAILURE TO SECURE RS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT AN EMPLOYER To <br /> CRIMINAL PENALTIES AND L FINES UP TO$100,600,IN ADDITION TO THE COST OF COMPENSATION,INTEREST, <br /> ATTORNEY'S FEES,AND p AGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. <br /> T O I R OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> i' (sig <br /> to of C-57 licensed authorized representative), <br /> hereby authorize(print name) i ` �� <br /> � ,to <br /> sign this San Joaquin county W II P it Application o , behalf. I understand this authorization is valid <br /> for one year and is limited to th work plan dated on the front page of this application. <br /> BI29X121rr1 <br /> EH02"l 115W <br /> WELL PERMIT APP <br />