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01,{04/10` 09: SRAM A11 Wel andonment 530.644.1439 <br />" 0 -15 --lo --.00 r5 <br />San Joaquin County Environmental Health Department Unit 111 Well Permit Application Supplement <br />JOB ADDRESS:_ �l �' ll ' ,��t 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 Division <br />3 of the Business and Professions Code and my license is in full force and effect. !� <br />License #; 4't Expiratic bate: �lJ <br />! aii <br />Date: �2-! Contractor: <br />Signature: <br />Printed name: V-0 1 E. 0 (Rlickna A. <br />WORKERS' COMPENSATION DECLARATION <br />I hereby affirm under penalty of perjury one of the following deciarations: (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 />YI'have and will maintain workers' compensation insuran=:e, 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: /yh f <br />Carrier: y �. � Policy Number: � ,1000 CDIC ---_ <br />certify that in the performance of the work for which th-s 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 p!ovisions of Section 3700 of the Labor Code, I shall <br />forthwith comply with those provisions.) <br />Expiration Date: Signatures <br />Printed Name: �r.1 <br />WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL, AND SMALL SUBJECT <br />AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL. FINES LIP 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 FORME THAN C -1'i7 SIGNING PERMIT APPLICATION <br />I, t `- -- signature ofC-67 licensed authorized representative), <br />hereby authorize (print name) L L L y \ am - <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 />8-29-021 MI <br />EHD 29-02-001 <br />61=04 <br />