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r i <br /> San Joaquin County Environmental Health Services, Unit IV Well Permit Application Supplement <br /> JOB ADDRESS: /SSS" PERMIT SR#: <br /> LICENSED CONTRACTORS DECLARATION (LCD <br /> I hereby affirm that I am licensed under the provisions of Chanter 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 9: V 04ZZ 7 Expiration Date: _ ///34/20d Z <br /> Date: /Z LD / ontractor. <br /> Signature: GiiL Title: <br /> Printed name: .. / + /3 ,n_ — <br /> WORKERS' COMPENSATION DECLARATION <br /> I here/by affirm under penalty of perjury one of the following declarations: (CHECK ALL THAT APPLY) <br /> Vhave and will maintain a ceitificate of consent to self-insure for workers'compensation, as provided for by <br /> 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 performance of the work for which this permit is issued. My workers' compensation insurance <br /> carrier and policy numbers are: <br /> Carrier. �/1 (� Sr 2�jj Policy Number: z -/—7 <br /> 1171-1 <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 1 <br /> should become subject to the workers'compensation provisi ns of Section 3700 of the Labor Code, I shall <br /> forthwith comply with those provisions. <br /> Date: I ziA27.1D7 Signature: e� <br /> Printed Name: <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 /> I' (CS7 licensed authorized representative),hereby <br /> authorize <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 /> 5-17-2000/Mi <br />