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San Joaquin County Environ ental Health Department Unit IV well Permit APPfica,ti1olnn Supplement <br /> JOS ADDRESS:_! �� () W SC� .PERMIT SR#: Qv r <br /> 0o yds <br /> LICENSED CONTRACTORS DECLARATION (LC.LD) <br /> I hereby zdfi,^n that I am licensed under the-provisions of Chapter 9(commencing with Section 7000)or Division <br /> 3 of the Busi�n-a-rfss and Professi ns Carl".and my license is in full force and ffect. <br /> License 9: 1 ���V L"( 'E <br /> XP <br /> ' <br /> a1tfo�n 140: <br /> Datr:_. Contra tor: <br /> Signature:_ Y Title: ' <br /> Printed name: ) <br /> WORKERS" COMPENSATlt3fl DECLARATION <br /> I hereby affirm undpr penalty of perjury Une of the followin®declaratbns; (CHECK ONE) <br /> I hava and will maintain a cartficate of consent to self-insure for workers' compensation,as provided for <br /> by Section 3700 of the Labor Coda, for the performance of the work forwhich thin permit Is Issued. <br /> I kava and will maintain workers' cornpensstion Insurance,as required by Section 8700 of the I nbor Code, <br /> for the performance of the work for which this patn'Iit is issued. My workers'=rnponeatien insurance <br /> carriarand policynumbe era: /,��' ^ '��(,� <br /> Carrier: C� Policy Number;— ! Lx — <br /> I certify that in tho performance of the work for which this permif Is issued, I shall not employ any parson it <br /> any manner so as to became subject to the workers' compensation law:of California, and agree that if I <br /> should become sut:ject to the workers'compen.V'on provisions n 3700 of the Labor Code, I shall <br /> forthwith comply with those pruviaions. <br /> Date: _Sig nature: <br /> Printed Name: 1 Y <br /> WARNING:PAILURF TC SECUKF WORKERS'COMPENSATION COVEPtAOE IS UNLAWFUL, D SHALL SUBJEct' <br /> AN EMPLOYER TO CRIMINAL PENALTIFS AND CIVIL FINFS UP TO ONC HUNDRED THOUSAND DOLLARS <br /> (51 00,000,),IN ADDITION TO THE COST OF COMPENSATION,INTEREST,ATTORNEYS FEES,AND DAMAGES AS <br /> PROVIDED FOR IN SECTION 5700 OF'THE LABOR COD),;. <br /> t T.HORIZATIO FOR 13� TNFRTHAN C-57 SIGNING PERMIT APPLICATION <br /> / r' G`/u _(slpnawra ofo-57 lic0nsud putnorizad repres cntritiva), <br /> hereby authorize(print ramal_. _. - - -�, <br /> to sign this elan Joaquin County Wall Permit Application on my behalf. I understand this nuUrorlratlan is valid for <br /> one(f)y®ar Ana Ic limped to tho work plan datod on the front papa of this applications <br /> ]. PC/XIRi;1 Fp; OG:'�RF] 'iii .`L2`.! i 01 00- <br />