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San Joaquln County Environmental Health Services,Unit-IV Well Permit Application Supplement <br /> JOB ADDRESS: ,y�_ h-fir P�RMIT SR#: <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#:, /4 Via. yd 7 _Expiration Date: l e <br /> Date: Z/9/d/ Contractor: 7,7,Q <br /> Signature: Title: X <br /> Printed name• <br /> WORKERS'.COMPENSATION DECLARATION <br /> I hereby affirm tinder penalty of perjury one of the following declarations: (CH ECK ALL THAT APPLY) <br /> t I have and will maintain.a certificate of consent to self-insure for workers'compensafion,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 for which this permIt Is Issued. My workers'compensation insurance <br /> carrier and policy numbers are: <br /> Carrier:� CC-� 2 /"CLil�IC��,/ Policy-Number., <br /> .., t/-,o a �-�`j <br /> D ce 5� a <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, I shall <br /> forthwith comply with those provisions. <br /> Date: -7 161 signature: <br /> Printed Nance: <br /> WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT <br /> AN EMPLOYER TO CRIMINAL,PENALTIES AND CMI,FINE$UP TO ONE HUNDRED THOUSAND DOLLARS <br /> IS100,000.j,IN ADOMON TOTTHE COST OF COMPENSATION,INTEREST,ATTdRNEV`S FEES,ANtf 13AMAGES AS <br /> PROVIDED FOR IN 69CTION STt16 OF THE LABOR CODE. <br /> b (0v7 licensed authorized representative),hereby <br /> authorize She el - <br /> to sign this San Joaquin County Well Permit Applica n on my behalf. I understand this authorization is valid for <br /> fone(4)year and is limited to the work plan dated an the front page of this application. <br /> i <br />