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IPI w Ur Ua)Ala David Fisch <br /> • 2092-3571 p.3 <br /> San Joaquin County Environmental Health Department Unit IV Well Permit Application Supplement <br /> JOB ADDRESS: / 0� )- / PERMIT SR#: Com/ 0„35? <br /> JfZCk�G <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#:_�[j ��1� <br /> Expiration Date: `—rj' /�7i010 <br /> Contractor: C.H L/illzr <br /> SignatureT7::�_ <br /> �T <br /> Title: [) <br /> Printed name:. 't fgjI/ <br /> WORKERS' COMPENSATION DECLARATION <br /> 1 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 <br /> 'Policy numbers are: <br /> Carrier.254 l fYl P �j - ��C) POlioy Number. Oaq Q p -r'1/,. <br /> 1 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 provisions of Section 3700 of the Labor Code, 1 shall <br /> forthwith comply with those provisions. <br /> Expiration Date:8Sd /q Signature: <br /> x it 49 Printed Name: DO,/I D Fj 5C t.1 <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 /> ($100,000.),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 /> '. signature ofC-57 licensed authorized representative), <br /> hereby authorize(print name) �o/rn /V — 5La7'1 <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 /> 622/04 <br />