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� San Joaquin County Environmental Health Departimnt Unit IV Well Permit Application Supplemental <br /> 4&JOB ADDRESS: r 1 , �C�� '�t, <br /> PERMIT SR# <br /> -------------- <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 force and e <br /> License#: a Q <br /> Exp�Date: <br /> Date: l- 1 1 '� �. <br /> ContractorY I t 1 <br /> nr <br /> Signature: <br /> Title: <br /> Print Name: V IV <br /> WORKER'S COMPENSA N 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 /> xI have and will maintain workers'compensation insurance, as required by Section 370 <br /> j Labor Code, for the performance of the work for which this 0 of the <br /> compensation insurance carne and policy numbers are: permit is issued_ My workers' <br /> Carrier: policy Number: <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 o <br /> agree that if I should become subject to workers f California, and <br /> Labor e, I sh I forthwithI compensation provisions of Section 3700 of the <br /> comply with those Prov" ' S. <br /> i <br /> Exp. Date: r <br /> Signature: r7_ <br /> Print Name: <br /> WARNING:FAILURE TO SECURE WORKER&COW ENSATHM COVERAGE IS UNLAWFUL,AND SHALL SUBJECT ANE EMPLOYER TO <br /> ATTORNEYS <br /> S FEETIES AND CML FINES UP TO$ <br /> 100,000,Di ADDITION TO THE COST OF COMUBJECT AN,IMtLOYE, <br /> ATTORNEY S FEES,AND DAMAGES AS PROVIDED FOR IN SECTION 3701;OF THE LABOR CODE. <br /> 1, <br /> /APDJOR OTHER THAN C-67 SIGNING PERMIT APPLICATION <br /> (signature of C-67 lkensed a <br /> hereby authorize(print name) 1� ^ �,' � udlor¢ed representative), <br /> sign this San Joaquin county Well Permit <br /> to <br /> Application on my behalf. I understand this auttwraation is valid <br /> for one year and is limited to the wow plan dated on the front page of this application. <br /> I <br /> ` 8129I021M1 <br /> EMD 2UI 114m-, <br /> WVLL PERY(T APP <br />