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San Joaquin County Environmental Health Services, Unit IV Well Permit Application Supplement <br /> JOB ADDRESS: PERMIT SR#: <br /> LICENSED CONTRACTORS DECLARATION (IGD} <br /> I hereby affirm that 1 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#: _-- _6 d-;Q Expiration Date: Z Yep 0 <br /> Date: 0 - Contractor ,I`1 or.444 1��)�`0✓1mP�7� <br /> Signature: Title: —f-cv1G <br /> Printed name: <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm under"penalty of perjury one of the following declarations: (CHECK ALL THAT APPLY) <br /> _i have and will maintain a certificate 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 /> 41 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: c!►n Policy Number- 3)7-Y 7 Y-0 y <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 /> [late: CJ Signature: <br /> Printed Name: 07 Ile]» &/J <br /> WARNING: FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CML 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 1N SECTION 3706 OF THE LABOR CODE. <br /> I, (C-57 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 /> 547-20001 MI <br />