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San.Joaquln County Environmental Health Department Unit IV Well Permit Application Supplement <br /> JOB AiDDRESS: a� C ' I cl._ PERMIT SRA.. 00%40WO <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#: Expiration Date: 0--A i A3 }- <br /> Date: I/44 a, Contractor: <br /> Signature: _ Title: L�= 1p A <br /> Printed name: <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm;under,penaltjof perjury one of the following declarations: (CHECK ONE) r <br /> x <br /> _I have and wilimaintain a certificate of consent to self-insure for workers' compensation,as provided for <br /> by Section 3700 o�the Labor Code,for the performance of the work for which this permit is issued. <br /> I have and w1h maintain'%t6rkers'compensation insurance, as required by Section 3700.of the La11or Code, <br /> for the performance of the wgrk for which this permit it issued. My workers' compensation insurhee <br /> carrier [lutnb rs are: , , <br /> Canxler:�n S' ,;Fw, '' Policy Number: /3 o <br /> I�oerl� tt at In r ttarrce of the work for which this permit is issued, I shall not eilhooy�anj,person in <br /> an manner so as t6 6 `asme'iu`' <br /> y bject to the workers"compensation laws of.,California �lnd agree that if I <br /> should become subject to the workers'compensation provisions of Section 3700 of tha Lalfr Code, I shall <br /> forthwith comply with those provisions. s `' <br /> Date: _ Signature: ' <br /> �r 1. <br /> printed Name: Dsrl ��•r�w.�� <br /> 44 <br /> WARNING:FAIkURE ITP SECURE'Wo RKERS'COMPENSATION COVERAGE IS UNLAWFUL#tAUD SHALL SUBJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THO��OLI ARS <br /> ($100,000.),IN ADDITION TO THE COST OF COMPENSATION, INTEREST,ATTORNEY'S FEE491 ND DAMAGES AS <br /> PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. . •. g <br /> AUTHORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APICATION <br /> I, S (signature ofC-57 licensed aakl�zed�epresentative), <br /> hereby ize(print name) <br /> to sign this San Joaquin County Well-Permit Applicatlowon my behalf. 1 understand-this aut Algation is valid for <br /> one(1)year and is limited to the workplan dated on thefront page of this ap`plicetiod. <br /> 8-29-02 1 MI <br />