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r <br /> i <br /> San Joaquin County Environmental Health Services,Unit W Well Permit Application Supplement <br /> JOB ADDRESS 4 PERMIT SR#: <br /> .�.� _. <br /> LIOENSM CONTRACTORS DECLARATION LCD) <br /> I hereby affirm that I ern 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 A IO 5Zo_ Yd 7 Expiration Date: ez <br /> Date: Z f�1/� — ---Contractor: re ^S/ <br /> Signature: / Title: <br /> Printed00 - <br /> name• !/� ��,� <br /> WORKERS'COMPENSATION DECLARATION <br /> i I hereby affirm under penalty of perjurer one of the following declarations: (CHECK ALL THAT APPLY) <br /> I have and will maintain a certificate of consent to self4nsure 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 /> _have and will maintain workers'compensation insurance, as required by Section 3700 of the Labor Code, <br /> for the performance of the work fpr which this permit is issued, My workers'compensation insurance <br /> carrier and policy numbers are, <br /> Carrier: C(-- / aC� Policy Number:, <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 of Section 3700 of the Labor Code,l shall <br /> ` forthwith Comply with those provisions. <br /> I Date: -71- <br /> 161 Signature: <br /> Printed Name: Q.r�i c{P:2.� ^•T�, <br /> WARNING:FAILURE TO St%CURE WORKERS'COMPENSATION COVERAGE;IS UNLAWFUL,AND SHALL SU13JECT <br /> AN EMPLOYF.RTO CRIMINAL,PENALTIES AND CML FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> ($100,000.),IN ADDITION TO THE COST OF COMPENSATION,INTEREST,ATTORNEY'S FEES,ANt]DAMAGES AS <br /> PROVIDED FOR(N SECTION 3706 OF THE LABOR CODE. <br /> 1, 0d7 licensed authorized representative),hereby <br /> authdrize �&7 ' <br /> to sign this San Joaquin County Well Permit Applira n on my behalf. I understand this authorization Is valid for <br /> one(1)year and is limited to the work plan dated an the front page of this application. <br /> 5-1740001 Ml <br /> i <br /> C <br />