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San Joaquin County Environmental Health Department Unit IV Wel) Permit Application Supplement <br /> JOB ADDRESS: (OJ W. d 7�alld- _ 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 Cade and my license is in full force and effect. <br /> License#: 420 kpC Expir�at on Date: <br /> Date: 7 d7 Contractor: (� <br /> Signature: /)C/ k/ _Title: <br /> Printed name: j�h� � X_ r _ <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the following declarations: (CHECK ONE) <br /> _', 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 /> ZI 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 P �U,rJ Policy Number: I�1 /-7 -/ / <br /> I certify that in the performance of the work for which this permit is issued, I shat: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. y� <br /> Expiration Date: I071-o6: Signature: <br /> v� <br /> Printed Name: )&%Y\a <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 /> AUTHORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> l� (signature ofC-57licensed authorized representative), <br /> hereby authorize(print name) <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 /> 622/04 <br />