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0110AL'I10 09:SOAI4 A11 Wei' kbandonment 530.544.1439 <br />P.03 <br />1 P p � 51 q "I 11"1 1� <br />San Joaquin County Environmental Health Department Unit IV Well Permit Application Supplement <br />JOB ADDRESS._ _Y�I._ PERMIT SR#: <br />LICENSED CONTRACTORS DECLARATION (LCD) <br />I hereby affirm that I am licensed under the provisions of Chspter 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 #;'t Expiratic n Date: �; 2 -0 - <br />Date: L �O � I -_ - Contractor. esil <br />Signature: Title: - <br />-- Y�- <br />Printed name: <br />WORKERS' 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 provided for <br />by Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. <br />l 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 i sued. My workers' compensation insurance <br />carrier and policy numbers are: <br />Carrier:o,�L_- IrU, Policy Number: 01 —10 () nq <br />I 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' co Tipensation 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. _ -.a <br />Expiration Date: (� Signatures <br />Printed Name: r <br />WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL SUBJECT <br />AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES t iP 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 FOR ER THAN C -'.1i7 SIGNING PERMIT APPLICATION <br />_ <br />.................. <br />[signature ofC-57 licensed authorized representative), <br />hereby authorize (print name) l }� _1 r <br />to sign this San Joaquin County Well Permit Application on n y behalf. 1 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 />E -HD 29-02-001 <br />6/22/04 <br />