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San Joaquin County Environmental Health Department Unit IV Well Permit Application Supplement <br /> JOB ADDRESS: ?n:) affg -upti1GtS ( PERMIT SR#: DSZ So 7 <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#_ _-7 0 ejC� <br /> Date: � ' • Q'7 <br /> Expiration Date: ©5' ) . 20D 8 <br /> � }2�, <br /> Contractor: f 1 (-Dyle-x Tnc <br /> Printed name: <br /> Signature:�( �� <br /> + Title:.Oce <br /> 1� ., mar)-h, 1 11r] p r2 <br /> Aa <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 Code, <br /> for the performcompensatio <br /> ance of the work for which this permit is issued. My workers' n insurance <br /> carder and Policy numbers are, / , - <br /> Carrier:�LGC y <br /> 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. <br /> Expiration Date: -4•o'^A Signature: <br /> �on� �}na <br /> Printed Name:--=-,�� '� �am�y_-4_ <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 /> 1, (signature ofC•57 licensed authorized representative), <br /> hereby authorize(print name) � t e(:ArQ D..f Kkinif•' lic(cip— <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 /> 8-29-02 t MI <br /> Fun aam_nn i <br />