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1 <br /> San Joaquin County Environmental Health Department Unit IV Well Permit Application Supplement <br /> JOB ADDRESS: `. 535 6, GL��o �{ PERMIT SR#: 0047-0q <br /> UCENSED CONTRACTORS DECLARATIONL( CD} <br /> 1 hereby affirm that I am licensed under the provisions of Chapter 9(commencing with Section 7000)of Division <br /> 3 of the Business <br /> ��and Professions Code and my license Is in full force and//e <br /> License#: T--7— ! Expiration Date: <br /> Date: L�% �- Contractor. �/ / I 1 t G ny.. <br /> Signature: / Titre: <br /> Printed natne• +144r-cl�Y- wyd,�nle <br /> WORKERS'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 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 ands policy numbers are : <br /> Canter: 1,r l I,I S, Policy Number:-(30SJ i00!0 l�`A(Q ._ <br /> I certify that in the performance of the work L which this permit is issued,i shall not employ any person in <br /> any manner so as to become$object to the workers'conipenaation laws of Caiifomia,and agree that if'1 <br /> should become subject to the workers'compensation provisions of Section 3740 of the Labor Code,I shall <br /> forthwith comply with those provisions. <br /> Expiration Date: Signature: <br /> Printed Name: <br /> WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUiJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND OIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> ($100,000.1 IN ADDITION TO THE COST OF COMPENSATION,INTEREST,ATTORNEY'S FEES,AND DAMAGES AS <br /> PROVIDED FOR IN SECTION 3706 OF THE LAISOR COOE- <br /> AUTHORIZATION FOR$TREK THAN C-57 SIGNING PERMIT APPLICATION <br /> (signrtunt ofC-fi7 liconsed authorized rcpresenlative), <br /> hereby authorize(prIntnamel�TI�I( Q <br /> to sign this San Joaquin County Well Permit Application on my behalf. t understand this authorization In valid for <br /> one(1)year and is limited to the work plan dated on the frond page of this application. <br /> 6-29-02 f IBI <br /> r�]4-m.001 <br /> 602104 <br />