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San Joaquin County Enviro tal Health Department Unit W Well Perm <br /> pplication Supplemental <br /> JOB ADDRESS: <br /> PERMIT SR # <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> I 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 my license is in full force and effect. <br /> License#: _ t_ 0q 04— E <br /> \\� Date: <br /> Date: Contractor.y k� Z}rt <br /> Signature: <br /> \ / Title: f J-1--- <br /> Print Name: V`I iri <br /> WORKER'S 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 <br /> Provided for by section 3700 of the labor Code, for the performance of the work for which this <br /> permit is issued. <br /> xI have and will maintain workers'compensation insurance, as required by Section 3700 of the <br /> Labor Code, for the performance of the work for which this permit is issued. My workers' <br /> compensation insuranncce,came and policy numbers are; <br /> Carrier: 1 (.0 1 Policy Number: <br /> I Certify that in the performance of the work for which this permit is issued, I shall not employ any <br /> person in any manner so as to become subject to the workers'compensation law of California, and <br /> agree that if I should become subject to workers' compensation provisions of Section 3700 of the <br /> Labor Code, I shall forthwith comply with those prov' ' ns. <br /> Exp. Date: <br /> Signature: <br /> 7 Z& I Print Name: <br /> WARNING:FAILURE TO SECURE WORKERS'COWPENSA710H COVERAGE IS UNLAWFUL, AN EMPLOYER TO <br /> AND SHALL SUBJECT <br /> CPot6NAL PENALTIES AND CML FIRES UP TO 5100.000,Ur ADDITION TO THE COST OF COWENSAT{ON,INTEREST, <br /> ATTORNEY'S FEES,AND DAMAGES As PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. <br /> I' �' <br /> �A T O I �1 R OTHER THAN C-67 SIGNING PERMIT APPLICATION <br /> (signature of C.6/licensed authorized representative <br /> hereby authorize(print name) ) <br /> sign this San Joaquin county Well Permit App cation on mG 'tO <br /> y behalf. I understand this authorization is valid <br /> for one year and is limited to the Work plan dated on the front page of this application. <br /> Br2"21M1 <br /> EH02"1 11W <br /> WELL PERYfT atm <br />