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v� , z, -30 <br /> San Joaquin County Environmental Health Department Unit IV Well Permit Application Supplemental <br /> JOB ADDRESS: 3535 East Cherokee Road PERMIT SR# ®�T <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 an/-,7deffect. <br /> License#: L � Exp Date: E !2 <br /> Date: �" Contractor <br /> Signature: <br /> Title: a e r <br /> Print Name: -7-z". <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 seff4nsure 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: Q' <br /> Carrier: tii �(� Policy Number: C� [J n5 <br /> 1 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: �__ I — U r c� <br /> _ Signature: <br /> Print Name: <br /> WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT AN EMPLOYER TO <br /> CRIMINAL PENALTIES AND CML FINES UP TO$100,000,IN ADDITION TO THE COST OF COMPENSATION,INTEREST, <br /> ATTORNEY'S FEES,AND DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. <br /> AUTHORIZATION FORQTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> . (signature of C-67 licensed authorized representative), <br /> he7this �J <br /> ze(print name) Lauren Cardinalli <br /> sioaquin county Well Permit Application on my behalf. 1 understand this authorization is valid <br /> fod is limited to the work pian dated on the front page of this application. <br /> EM zeal 11MW O� Ile W/A WA� Nt <br /> . WEM PEwarr APF <br />