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San Joaquin County Environmental Health Department Unit IV Well Permit Application Supplemental <br /> JOB ADDRESS: 121 q 5 N Tho ir,-b o PE RMIT SR# <br /> LICENSED CONTRACTORS DECLARATION (LCD} <br /> i <br /> I hereby affirm that I am licensed under the provisions of Chapter 9(commencing with Section 7000) of i <br /> Division 3 of the Business and Professions Code and my license is in full force and effect. <br /> License#: t _ E xp Date: <br /> Date: ti �� t <br /> d c _Contractor. Cain �Ci<2sJfc CO. <br /> Signature: ,� Titie: —057-O r It:S I4lex-1` -- <br /> Print Name: 1.4 <br /> i 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 /> � I <br /> I 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.S,u4,,L- c-t . Policy Number: 1-A30- <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 Califomia,and <br /> agree that if I should become subject to workers'compensation provisions of Section 3700 of the <br /> Labor Code,I shall forthwith comply with those provilSaDns: <br /> Exp.Date: vt;h '�J!-Signature: <br /> T <br /> Print Name: <br /> i WARNING:FAILURE to SECURE WORKERS'COMPENSATION COVERAGE IS UNi-AWFUL,AND SHALL SUBJECT AN EMPLOYER TO <br /> } CRIMINAL PENALTIES AND CIVIL FINES LIP TO$106,000,IN AODITTON TO THE COST OF COMPENSAVON,INTEREST, <br /> ATTORNEY'S FEES,AND DAMAGES AS PROVIDED FOR IN SECTION 37%OF THE LABOR CODE. III <br /> AUTHORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> (signature of C-57 Licensed authorized representative), E <br /> hereby authoflze(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 /> erasr67rsI1 <br /> EH❑26x1 i,FA7 MEL',f{RNR a,pa <br />