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C <br /> r�) <br /> San Joaquin County Environmental Health Services,Unit IV Well Permit Application Supplerfient <br /> J.l. boom LS �� PERMIT SR#: -° <br /> JOB ADDRESS: � �T <br /> N <br /> LICENSED CONTRACTORS DECLARATION <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: 1- - <br /> Date: Contractor: 01WO <br /> Signature: Title: 01,0- QA <br /> Printed name: <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 /> /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: 15,310 <br /> 2,6cJ <br /> 1 certify that in the performance of the work for which this permit is issued, I shall not employ any person in <br /> any mariner so as to became 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, t shall <br /> forthwith comply with those provisions, <br /> Date: `�d Signature: <br /> Printed Name-, 1 Jay,k <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 HUNG RED THOUSAND DOLLARS <br /> (3100,000.),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 /> 1, —Davi J f;SC.k4 (C-57 licensed authorized representative),hereby <br /> ��(1l 1 to d 7ze-o <br /> authorize __ _ _ <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 /> Zd Wd4Z:b0 0002 ZZ '6nd 2886 828 602 : 'ON dNOHd STS61eud ojaZ punouro WDa� <br />