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t_ <br /> San Joaquin County EnvironmentaleAxh St Seerv�l-cea,Unit IV Well PlrmitApplication Supplement <br /> JOB ADDRESS: ufK^ MRM!`C SRN!a of <br /> rceL Cio,� <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> i <br /> I 1 nereby affirm that I am I"wonsed under tho provisions of Chapters(commencing with sectior. 7000)of Civisron <br /> 3 of the Business and Professions Code and my license is in full force and effect. <br /> .7a Q� Expiration Cate: <br /> License S, <br /> Dole, _'= 0 rdratctor: <br /> I <br /> signature: f / Tltb: �0 <br /> Printed name: <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the fol;owing declarations: (CHECK ALL THAT APPLY) <br /> I have and will maintain a certificate of consent to self-insure for workers' oompensetion.as provided for by <br /> Section 3700 of the Labor Code,for the parlor <br /> of the week for which this permit is issJed. <br /> I have ane will maintain workers,compensation insurance, as -squired by Secaon 3700 of the Labor;;ode, <br /> for the performance of tho work for which this permit is issued. My workers'compensation insurance <br /> carrier and policy lumbers are: <br /> Carrier.yl- L 1� Policy Number: <br /> I certify that in the peftmance of the work for which this permit is issued, I shaft not employ any person in <br /> any manner so as to become SAW to the workers' compensation laws Of California,and agree that if 1 <br /> should become Subject to the workers'compensation provisions of Seerion 3700 of the Labo,Code. I shall ' <br /> torthwith1compty with those provisions. J'� • ., I . <br /> Date: ✓ Signature:_4aL <br /> 'A 1,r' I <br /> Printed Name: <br /> I AN t:at LP OYER TO CRIMINAL PENALTIESR&NO CMLFI ES UP TO ONCE HUNDRED THOUSAND SHALL HUNDRED <br /> j <br /> (b1pD,000.),IN ADDIT)ON TO THE COST OF COMPENSATION,INTEREST,ATTORNEY'S FEES.AND DAMAGES AS �I <br /> PROVIDED FOR IN SECTION 3706 OF THE LABOR COOS. <br /> _� C-57 0eansed' utho ', reprseMEattve), hereby I <br /> audrarl7.e 1 <br /> to sign this San Joaquin County Well Permit App isation on my, behalf. 1 understaAd this sutnoriuHon is valid for <br /> on! 1 ear end m Dmtbd to tele work ion dated on dor`front page 01"11 application. ' <br /> ' 1 <br />