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�- 4AW'�� <br /> San Joaquin CountyLEnviran ental Health Department Unit IV Well Permit A.PPI(cation Stir�plament 1 <br /> JOB ADDRESS:_ C� 'PERMIT $R#1 Dv ��LL <br /> 90 YY6 <br /> LICENSED CONTRACTORS DECLARATION (LCIS) <br /> I horeby affirm that I am licensed under thp previalons of Chapter 9(cornmencing with Section 7000)or Division <br /> 3 of the aysin-e-lss'and Professi ris Codr.and my license is in full forte and ffect I <br /> License S: 1 O vC� EaP at(on[)/at '1 V� <br /> 1]atr_:—_ Contra^toc <br /> _ <br /> Signature:— 71t1a; <br /> Printed name: <br /> WORKERS' COMPENSATW DECLARATION <br /> I hereby affirm under penalty of parjury one of the fallowing deClarationa: (CHECK ONE) <br /> I have and will maintain a tort ficate 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 tALn permit Is Insued. <br /> X I have and will maintain workars'compensstlon Insurance,as required by Section 3700 of the I mbor Code, <br /> for the performance of the work for which this permit is issurd. My workers'campen6aticn Insuranoc <br /> Darfur en polfoy numbe aro: �7 <br /> Carrier: Policy Number: <br /> I certify that in the performance of the work for which this permit Is issued, I shail not employ any person iri <br /> any manner so as to become sublact to the workers'compensation laws of California, and agree that if I <br /> should beco a suh(scI to the workers'compensa inn provisione of 6rdlon$700 of the Labor Code, I shall <br /> forthwith comply with those provisions. 7 <br /> Date:— _Signature: r )( <br /> Printed Name:1T' C i1(L--- <br /> WARNING;FAILURE TC SECURE WORKCRS'COMPENSATION COVERAGE IS UNLAWFUL,at7 D SHALL SUBJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINFs UP TO ONG HUNDRED THOUSAND DOLLARS <br /> (1100,000,),IN ADDITION TO THE COST of COMPENSATION,INTEREST,ATTORNEYS rEES,AND DAISAGCS AS <br /> PROVIDED FOR IN SECTION 7706 OF THE LABOR CODE <br /> THORIZATIO FOR d_ TFfERTHAN C57 SIGNING PERMIT APPLICATION <br /> 4 �N�^�,���- _(alpnawre ofC-37 licensed authodurd represcntativa), <br /> hereby artihoriz (print - <br /> ta sign this San Joaquin County Well Pcmait Application on my behalf. I undarsland this aulhurirottan is valid for <br /> one(1)yaar and Is limited to the work plan lord on the front pelta of this application. <br /> 8-n-0211%11 <br /> 1t2fai20UJ 7R 0 LTX/RA NO ,2223 3IW2 <br />