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San Joaquin County <br /> CEnvironmental Health Department Unit IV Well Permit Application Supplemental <br /> JOB ADDRESS: 16 ` ( L- I(G 0644_PERMIT SR# <br /> /A,C4-A1, OA- 9 533 <br /> OgIuv VJ LLk�� <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> I hereby affirm that I am licensed under the provisions of Chapter 9(commencing with Section 7000) of <br /> Division 3 of the Business and Professions Code and my license is in full f rce and effect. <br /> License#: C 5 4 Fxp Date: 38 I Z <br /> Date: Contractor: E j Pr( t, <br /> Signature: (tel Title: I��u���___.___ _ <br /> Print Name: <br /> 44,> <br /> WORKER'S 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 <br /> provided for by section 3700 of the labor Code,for the performance of the work for which this <br /> permit is issued. <br /> 1 have and will maintain workers'compensation insurance, as required by Section 3700 of the <br /> Labor Code,for the performance of the work for which this permit is issued. My workers' <br /> compensation insurance carrier and policy numbers are: <br /> Carrier. T Policy Number: ()QOq-) 3336 32 co-Z <br /> I certify that in the performance of the work for which this permit is issued, I shall not employ any <br /> person in any manner so as to become subject to the workers'compensation law of California, and <br /> agree that if I should become subject to workers'compensation.prwisions otSection 3700 of the <br /> Labor Code, I shall forthwith comply with those provisions. <br /> Exp. Date: l 0._' I _2 Signature: xor <br /> Print Name: <br /> WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT AN EMPLOYER TO <br /> CRIMINAL PENALTIES AND CIVIL FINES UP TO$100,000,IN ADDITION TO THE COST OF COMPENSATION,INTEREST, <br /> ATTORNEY'S FEES,AND DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. <br /> WTHORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> I, enJn/t S (signature of C-57 licensed authorized representative), <br /> hereby authorize(print name) to <br /> sign this San Joaquin county Well Permit Application on my behalf. I understand this authorization is valid <br /> for one year and is limited to the work plan dated on the front page of this application_ <br /> 81291071M1 <br /> EI ID 29-01 1115W VYf:11 Pi RMI I AI'F <br />