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�xW <br /> t <br /> San Jo gain ounty Environmental Health Denartment UnIt tV Wel[Permit Application Sup Ism tai <br /> J08 ADDRESS: ERMIII SR# <br /> ' LICENSED CONTRACTORS DEC ILARATO14 (LCD) <br /> 1 hereby affirm that I am licensed under the provisions of Cha er 9(commencing with Section 7000)of } <br /> Division 3 of the Business and Professions Code and cense is'in full force and effect. l <br /> 1 License#: tp �({p s Exp Dab. <br /> Date: �J'1-7- 10 Contractor: 1 S <br /> Signature Title: <br /> I f <br /> Print Name.,-- <br /> 5 )O", <br /> li WORKER'S COMPENSATION DECLARATION <br /> 1 hereby affirm under penalty of perjury one of the following declarations:(check one) <br /> jI have and will maintain a certificate of consent to self-insu II 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 /> _. have and will maintain workers'compensation insurance,,Is required by Section 3700 of the <br /> Labor Code,for the performance of the work for which this permit is issued. My workers' <br /> i compensation insurance carrier and policy numbers are: <br /> Carrier;S Policy�Q y Number: . 010 <br /> ti i certify that in the performance of the work for which this pelrmit is issued,I shall not employ any <br /> person in any manner so as to become subject to the workelrs'compensation law of California,and <br /> agree that if I should become subject to workers'compensation provisions of Section 3700 of the <br /> I Labor{Code,i shall forthwith comply with thoseprovisions. <br /> Exp.Date:�1— Signature: " <br /> Print Name: <br /> WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT AN EMPLOYER TO <br /> i CRIMINAL PENALTIES AND CIVIL FINES UP TO 5100,000,IN ADDITION TO�HE COST OF COMPENSATION,INTEREST, <br /> ATTORNEY'S FEES,AND DAMAGES AS PROVIDED FOR IN SECTION 3706OFTHE LABOR CODE. <br /> c <br /> AUTHO N FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> j 6 (signature of C-,5/7 licensed authorized representative), <br /> hereby authorize(print name) lC rig-°lGE, C?Zl't to j <br /> sign this San Joaquin county Well Permit Application on my behalf. II understand this authorization is valid I <br /> for one year and Is limited to the work plan dated on the front page of this application. <br /> s arzvn2rM1 <br /> Ill <br /> t EHD 29113 M5107 <br /> WELL PERh9i MF <br /> I <br /> t <br /> f <br /> i <br /> I <br /> r <br />