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San Joaquin County Environmental Health Department Unit IV Well Permit Application Supplement <br /> JOB ADDRESS: 1600 W , eA ihr'c,k PERMIT SR#: <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> I hereby affirm that I am licensed under the provisions of Chapter 9(commencing with Section 7000) of Division <br /> 3 of the Business and Professions Code and my license is in full force and effect. <br /> License#: ce%0 J,—] Expiration Date: L,A) <br /> Date: Contractor: n <br /> Signature: Z—��777Title: V r <br /> Printed name: , <br /> WORKERS' COMPENSA ION 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 and <br /> �c7T�k policy numbers are: i <br /> Carrier: C wVA%�SA-SA (7yyd Policy Number: <br /> I certify that in the performance of the work for which this permit is issued, I shall not employ any person in <br /> any manner so as to become subject to the workers' compensation laws of California, and agree that dl <br /> should become subject to the workers' compensation Prov. ions of Section 3700 of the abor Code, I shall <br /> forthwith comply with those provisions. <br /> Expiration Date: Signature: <br /> Printed Name: k ✓ <br /> WARNING: FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNL FUL,AND SHALL SUBJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED HOUSAND DOLLARS <br /> ($100.,000.),IN ADDITION TO THE COST OF COMPENSATION,INTEREST,ATTORNEY'S FEES,AND DAMAGES AS <br /> PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. <br /> ,,AUTHORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> l <br /> _(signature ofC-57 licensed authorized representative), <br /> hereby authorize(print name) C f�/l� S�t <br /> to sign this San Joaquin County Well Permit Application on my behalf. I understand this authorization is valid for <br /> one(1)year and is limited to the work plan dated on the front page of this application. <br /> 8-29-02/MI <br /> EHD 29-02-001 <br /> 6/22/04 <br />