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s 1 <br /> San Joaquin County Environmental Health Services,Unit IV Well Permit Application Supplement <br /> JOB ADDRESS- 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 <br /> �and Professions Code and my license is in full force and effect. <br /> License#: J ca► (�7 Expiration Date: �.- <br /> Date: --CXR ntractor: <br /> SignatureTitle: <br /> . <br /> /1,eJl l <br /> Printed na Vi — <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the following declarations: (CHECK ALL THAT APPLY) <br /> I have and will maintain a certificate of consent to self-insure for workers' compensation,as provided for by <br /> _Section 3700 of the Labor Code,for the performance of the work for which this permit is issued. <br /> V/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 policy numbers are: <br /> Carrier, � - Policy Number:^' .1_ ala <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 if I <br /> should become subject to the workers'compensation provisions of Sect" n 3700 of the Labor Code, I shall <br /> forthwith comply with those provisions. <br /> Date: t/7'� Signature: <br /> Printed Name: <br /> WARNING: FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND 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 /> I, (C-57 licensed authorized representative),hereby <br /> authorize <br /> to sign this San Joaquin County Well Permit Application on my behalf- I understand this authorization is valid fos <br /> one(1)year and is limited to the work plan dated on the front page of this application. <br /> W0HA WIvvS:©l 666 1-VO-O t <br /> c •..i <br />