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'wool, - <br /> San Joaquin County Environmental Health Services,Unit iV Well Permit Application Supplement <br /> JOB ADDRESS: '� ERMIT SR#:-0--t0Z Z <br /> LICENSED CONTRACTORS DECLARATION {LCD) <br /> I hereby affirrrl 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#: ly S 7 ,• tj Expiration Date: <br /> Date: Contractor: oil 1_ hT�--!-f- -�� <br /> Signature: JTitle: <br /> Printed deme-, <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the following declarations: (CHECK ALL THAT APPLY) <br /> Xl have and will maintain a certificate of consent to self-insure for workers'compensation. as provided for by <br /> Section 3700 of the Labor Cade,for the performance of the wortk for which this permit is issued. <br /> -9I 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: GrGL iodrrker Policy Number:u) <br /> I certify that in the performance of the work for which this permit is issued, I shall not employ any person in <br /> —arry 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 Section 3700 of the Labor Code, I shall <br /> forthvAth comply with those provisions. <br /> Date: �`lj Signature: <br /> Printed Name: <br /> WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE 18 UNLAWFUL,AND SHALL SUBJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> PROVIDED ISECTION 3706 OF THE LA <br /> ADDITION TO THE COST OF <br /> BOR CODE.ON,INTEREST,ATTORNEY'S FEES,AND DAMAGES AS <br /> FOR <br /> (signature ofC-57 licensed authorized representative), <br /> hereby authortze(print name)_ &L2, azee &, <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 /> 6-17-20001 MI <br /> 71L 968,4 .`eb:oL Lo-oz-6nv `•Z0£0 £L£ 5Z6 `• 'aur `6uz}sal V 6uiTTTJO 66aJ£ :lig WaS <br />