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. „mens 530.644.1439 <br /> • p.03 <br /> San Joaquin County Environment I Health Department Unit IV Well permit Application Supplemental <br /> JOBADDRESS: �, I <br /> PERMIT Sp itDr0oo_�—_ <br /> LICENSED CONTRACTOR DECLARATION (LCD) <br /> 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 <br /> License#: my license is in full force and effect. <br /> Qj3 I <br /> Date: <br /> Exp Date:/(j� j� .. � If <br /> t'h <br /> Signature Contractor:PI t 1 O tAw n r/vn y n <br /> � � + <br /> Print ame: Title:i- <br /> WORKER'S COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the followinill declaratio.'s: (check one) <br /> I have and will maintaina 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 /> I have and will maintain workers'compensation ins trance, as required by Section 3700 of the <br /> Labor Code, for the performance of the work for wl iich this permit is issued. My workers' <br /> compensation insurance carrier and policy numbers are: <br /> Carrie►: ��"1 ,�.Q �- I y1� <br /> -- � Policy Number: ( 1 -1000 - <br /> I certify that in the performance of the work for which this permit is issued, I shall not employ any t <br /> person in any manner so as to become subject to tie workers'compensation law of California, and <br /> agree that if I should become subject to workers'a)mpensation provisions Of Section 3700 of the <br /> Labor Code, I shat forthwith comply with those pro✓isions. <br /> Exp. Date: <br /> Signature: <br /> Print Narr a: <br /> WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT AN EMPLOYER TO <br /> CRIMINAL PENALTIES AND CIVIL FINES UP TO 510(1,000,IN ADDITION TO THE COST OF COMPENSATION,INTEREST, <br /> ATTORNEY'S FEES,AND DAMAGES AS PROVIDED FOR IN SEC r1ON 3706 OF THE LABOR CODE. <br /> ►, -�' E THA C-57 SIGNING PERMIT APPLICATION <br /> signature of C-57 licensed authorized representative), <br /> hereby authorize(print name) ! <br /> sign this San Joaquin county Well Permit A plication on my behalf. I understand this authorization <br /> to <br /> for one year and is limited to the work plan dated on the front page of this application. is valid <br /> 8129Po2/MI <br /> EN029.01 1MD7 <br /> WELL PERMIT APP <br />