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FSan Joaquin County Environmental Health Services, Unit IV Well Permit Application Suppllee�m�e/nt <br /> JOB ADDRESS: 19(n0 W Ilt` ��i*L.rt PERMIT SR#: S� 0 �'T! V <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#: C.S 7 (W."t -r— Expiration Date: a/ /3 //O R <br /> Date: LO7 Contractor:(AwQ 0,6, inti afl' /&o <br /> Signature: ®/1LKPiC� Title: <br /> Printed name: Or <br /> WORKERS' COMPENSATION DECLARATION <br /> 1 hereby affirm under penalty of perjury one of the following declarations: (CHECK ALL THAT APPLY) <br /> XI 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 /> XX ' 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: a9LYG1_6rCgnl Policy Number: We,Z/1"OXxx0 <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 <br /> of Section 3700 of the Labor Code, I shall <br /> forthwith comply with those provisions. ���� <br /> Date: Rheb0411w- <br /> Printed <br /> z%� <br /> � Signature: 7 1 <br /> Printed Name: _ 7 / A /Y"d <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 /> I,�!��y !/ / /'U/►� (signature ofC-57 licensed 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 /> 5-17-2000 i MI <br />