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1 <br /> San Joaquin County Environmental Health Department Unit IV Well Permit Application Supplemental <br /> JOB ADDRESS: �)t'`>I S �1}t''S `► ��"�' f"`{ PERMIT SR# <br /> iA—i-i , QA <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 effect. <br /> License#: Exp Date: <br /> Date: -2�� �� Contractor: C I C_ <br /> Signature:l'_ �a� ��� 1�� Q:"..� Title: tc Print Name: <br /> Name <br /> WORKER'S 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 <br /> provided for by section 3700 of the labor Code, for the performance of the work for which this <br /> permit is issued. <br /> 1 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 carrier and policy numbers are: (� <br /> Carrier: ` 1J ` 1 j 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 provisions. <br /> Exp. Date:___ ?S f c; (� Signature: <br /> 1 <br /> Print Name: < �WARNING:FAILURE 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 1706 OF THE LABOR CODE. <br /> AUTFi IZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> }. y (signature of C-57 licensed authorized representative), <br /> r�C. to <br /> hereby authorize(print name) <br /> sign this San Joaquin county Well Permit Application on my behalf. I understand this authorization is valid <br /> for one year and is limited to the work plan dated on the front page of this application. <br /> R1291021MI - <br /> 4ELL PERMIT APP <br /> END 2401 11`C <br />