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San Joaquinmy E Iran. tal Health Deparrtt=t Unit iv Well P•it Application Supplemental <br /> JOB ADDRESS: I60�/ S / PERMIT SR # 461 ,956 <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 and eflact. <br /> License #: . t o Exp Date: ' <br /> Date: <br /> e <br /> Signature: Title: <br /> Print Name: t-be'f+ V 71121pe,� <br /> { <br /> WORKER'S COMPENSA N 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 <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 Carrie and policy numbers are: <br /> Carrier: Policy Number: '`(/ �� <br /> I 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 provis ns/. / <br /> Exp. Date: Signature: - � ~ -- <br /> Print Name: f�Obf-r -- OL' <br /> ' <br /> WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT AN EMPLOYER TO <br /> CRIMINAL PENALTIES AND CIVIL FINES UP TO$100,000,IN ADDITION TO THE COST OF COMPENSATION,INTEREST, <br /> ATTORNEY'S FEES,AND DAMAGES AS PROVIDED FOR IN SECTION 7706 OF THE LABOR CODE. <br /> I �jOB�,jfQN R OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> L l %/ (signat4re of G-ST lic�nsedauthorized representative), <br /> hereby authorize (print name) �i_ i c '! ' � ' t ( { ' <br /> to <br /> sign this San Joaquin county Well Permit Application on -' <br /> PP my behalf. I understand this authorisation Is valid <br /> for one year and Is limited to the work plan dated on the front page of this application. <br /> ERI]29-01 1115v T <br /> WELL PERMIT APP <br />