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zJ c � <br /> Z�3 kA'A158'DdD <br /> San Joaquin County Environmentdl Health Department Unit IV Well Permit Application Supplement <br /> JOB ADDRESS: h � ' U1° PERMIT SR#: 0051 1D <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.r? <br /> License#: aOd--t('33�' Expiration Date:. 110 c <br /> Date: . !/t� 0T Contractor: 1 U C as kyi-t, VOnlC �Y1��. <br /> SignaGlre:L/� L �� Title:�[(p �ecS Id e of <br /> Printed name: Do) w 1 VICI If 1 > }l 1 <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the following declarations: (CHECK ONE) <br /> _I have and will maintain a certificate of consent to self-insure for workers'compensation, as provided for <br /> by 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 Cade, <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: s2we �T cuyj Policy Number: <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 Section 3700 of the Labor Code, I shall <br /> forthwith comply with those provisions. Q �J <br /> Expiration Date: la ( 0+ Signature: '`/�( �/Cr vv ( Q <br /> Printed Name: -1v-) wl vtqe UJI C <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 /> AUTHORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> (signature ofC-67 licensed authorized representative), <br /> hereby authorize(print name) U 01 <br /> to sign this San Joaquin County Well Permit Application on m 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 /> 8-29-02 1 MI <br /> EHD 29-02-001 <br /> 6/22(()1 <br />