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T. <br /> Ifrk <br /> tmlt A Iication Supplemental <br /> San Joaquin County Environmental Health Department Unit IV Well Pe pp <br /> JOB A©DRESS: ��� t✓ '�'^'t°v` � 1. tk�N .PERMIT SR# <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> rovisions of Cha 1 <br /> 1 hereby affirm that 1 am licensed under the.p ter 9 {commencing with Section 7000) of A <br /> Division 3 of the <br /> Business and Professions Code and my license is in full force and effect. <br /> License Exp Dater �O <br /> Date: 2� + Contractor„ V�u <br /> Signature: Title: <br /> Print Name: <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 /> . 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 /> 4 compensation insurance carrier and policy numbers are: <br /> Carrier: s�aL-f— FU Policy.Number: 00D bQ <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 provisions of Section 3700 of the <br /> Labor Code, I shall forthwith comply with those provisions. <br /> Exp:Date: Q: Signatures <br /> Print Name: <br /> E <br />{ WAFiNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT AN EMPLOYER TO <br /> Ij CRIMINAL PENALTIES AND CIVIL FINES OF 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 /> O -R-T-ttAN C-57 SIGNING PERMIT APPLICATION <br /> I (si 'nature of C-57 licensed authorized representative), <br /> hereby authorize (print name) EX l 'D.^1� rG 1 �1.0��-'�y'_t«►'�a'Y°i+" 1�c�---- ,to <br /> sigh 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 /> 41291021M1 <br />{ <br /> I}' <br /> 611D 2901 .1115177 WELL PERMIT APP <br /> 9 <br />