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San Joaquin County Environmental Health Department Unit IV Well Permit Application Supplemental <br /> .SOB ADDRESS: 2360 East Avenue, Tracy, CA PERMIT SR# a /(D 236 <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> hereby affirm that I am licensed under the provisions of Chapter 9 (commencingwith Secti n 7000) of <br /> Division 3 of the Business and Professions Code and my license is in full force and effect. <br /> License#: P9 6 S 6 It Exp Date: 110001 <br /> Date: j /III -koow Contractor:-'JAG C9 i f o^,«i, <br /> Signature: —IbL Title: R <br /> Print Name: <br /> WORKER'S COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the fallowing 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 /> X- I 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 insurance carrier and policy numbers are: <br /> Carrier:_5At& Flkl6k Policy Number: MOC93- 2,00$ <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 CalTornia, and <br /> agree that if I should become subject to workers' compensation provisions of Section 3700 of the <br /> Labor Cod , I sh all forthwith comply with those provisions. <br /> Exp. Date: Bq <br /> f Signature: <br /> Print Name: <br /> WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT AN EMPLOYER TO <br /> CRIMINAL PENALTIES AND CIVIL FINES UP TO$100,000,IN ADDITION TO THE COST OF COMPENSATION,INTEREST, <br /> ATTORNEY'S FEES,AND DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. <br /> AUTII,LQRIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> I, (signature of C-57 licensed authorized representative), <br /> hereby uthorize (print name) John Lane, Lee & Pierce, Inc. to <br /> sign this San Joaquin county Well Permit Application on my 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 /> sr29r021MI <br /> EHE 29-01 11/5M7 WELL PERMIT APP <br />