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San Joaquin County Environmental Health Department Unit IV Well Permit Application Supplement <br /> JOB ADDRESS' 2 f-�-eeo kF� L,A, LUr.{r <_,E� PERMIT SR#: <br /> I <br /> LICENSEE? CONTRACTORS DECLARATION CCD) <br /> J hereby-affirm that I am licensed Under the provisions of Ghapter9 (commencing with Section 7000)of Division i <br /> 3 of the ausiness and Professions Code and any license Is in full force and effect. <br /> Expiration Date: <br /> Date: �� ! '�`� Contractor Wz LIA <br /> Signature: - Title. <br /> Printed name: CDAC",d,� <br /> WORKERS' COMPENSATION DECLARATION <br /> I harebyaffirm underpenalty of perjury are of the following declarations: (CHECK ONE) <br /> have and will maintain a certificate of consort to self-insure far 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'compenselion insurance,as required by Section 3700 of the Labor Gode, <br /> for the performance of the worts for which this permit Is Issued. My workers'cornpen5ation insurance <br /> carrier and policy numbers are: i <br /> Carrier: S/dL*4t Policy Number: — <br /> I certify that In the perfonmance of the work for which this permit Is Issued,I Shall not employ any person in <br /> any manner so as to become subjact to the workers'compensation lays of Ca fom:a,and agree that if <br /> Should become subject to the workers'compensaflon provisions of Section 3700 of the Labor Code,I shall <br /> forthwith comply with those provisions. <br /> Expiration Date: It] -0-4 Signature: �r W <br /> Printed Name: Cts �. k�tlDaol <br /> WARNING:FAILURE TO SF-CURE WORKERS'COMPENSATION COVERAGI=is UNLAWFUL,AND SHALL SUSJECT i <br /> AN EMPLOYER TO CWMINAL PENAL7TES AND CIVIL.FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> ($100,000,),IN ADDrrl0N TO THE COST OF COMPENSATION,INTEREST.ATTORNEY'S FEES,AND DAMAGES AS <br /> PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. i <br /> iAUTHORIZATION FOR 07F1ER THAN C-57 SIGNING PERMIT APPLICATION i <br /> i, 17. W (signature ofC,57 licensed authorized representative), <br /> hereby authorize(pant nom.) ���uk �4�u " L(v 1 u ` �Pvt (G,r�e r <br /> IQ sign this San Joaquin County Well PermitApplioation on my b6fiali. I understand this authorization is valid for <br /> one(1)year and is limited to the work plan dated an the front page of this application. i <br /> B-29.02 1 MI <br /> ES f;7 79A2-OO I <br /> h.'ZZrt7S <br />