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s <br /> San Joaquin County Environmental Health Department Unit IV Well Permit Application Supplemental <br /> JOB ADDRESS: _SK0 V� oa-� 1�c�� 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 <br /> Division 3 of the Business and Professions Code and my license is in full force and effect. <br /> License#: i co Sf Exp Date: <br /> Date: Contractor: r <br /> Signature: Title: <br /> Print Name: <br /> WORKER'S 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 <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'compensation insurance, as required by Section 3700 of the <br /> Labor Code, for the performance of the work for which this permit is issued. My workers' <br /> compensation insurance carrier and policy numbers are: <br /> Carrier: Ay r-S Policy Number: �Id ixJ0 10 1 <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 manner so as to become subject to the workers'compensation law of California, and <br /> agree that if I should become subject to workers'compensation provisions of Section 3700 of the <br /> Labor Code, I shall forthwith comply with those provisions. <br /> Exp. Date: Signature: <br /> Print Name: <br /> WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT AN EMPLOYER TO <br /> CRIMINAL PENALTIES AND CIVIL FINES UP TO$100,000,1N ADDITION TO THE COST OF COMPENSATION,INTEREST, <br /> ATTORNEY'S FEES,AHDIpAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. <br /> UT OR T# OR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> I, (signature of CZ7 licensed authorized representative), <br /> hereby auth riz {print name) 5 to <br /> sign this San oaquin county Well Permit Application on my behalf. understand this authorization is valid <br /> for one year and is limited to the work plan dated on the front page of this application. <br /> W291021M! <br /> FH0 2HI 1116M7 WELL PERMIT APP <br />