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San Joaquin County Environmental THealth Department Unit IV Well Permit Application Supplement <br /> JOB ADDRESS: 0� tgf rt Q�t O►�I-Sy . PERMIT SR#. �/_'�l <br /> b � <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> I hereby affirm that I am licensed under the provisions of Chapter 9 (commencing wit Section 7000) of Division <br /> 3 of the Business and Professions Code and my license is in full force an//deff ct. <br /> II <br /> License#: Expiration Date: <br /> Date: (' Contractor / / ,/Co <br /> Signature Al Title: / ra.S/ tN <br /> Printed name: Lc—lo Q' i �tl <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjurylione of the following declarations: (CHECK ONE) <br /> _I have and will maintain a certificate of consent to self-insure for workers' compensation, as provided for <br /> by Section 3700 of the labor Code, for the performance of the work for which this permit is issued. <br /> I 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: �//(�y/{J/f} 'sVt`e l ^ Policy Number: <br /> J <br /> I certify that in the performance of the work for which this permit is issued, I shall not employ any persyn in 1 <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: Signature: <br /> Printed Name: <br /> u n <br /> 'WARNING: FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> x($100,000.), IN ADDITION TO THE COST OF COMPENSATION, INTEREST,ATTORNEY'S FEES,AND DAMAGES AS <br /> PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. <br /> ALITHO IZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> i ( .(sign�ature ofC-57 licensed authorized representative), <br /> hereby authorize (print name) Ax S/17'A YIJ� I i'! ` r p_!6,AJ ��1��/bn/7JP•//f�%i¢'/ <br /> to sign this San Joaquin County Well Permit Application on my behalf. I understand this authorization is valid for <br /> one (1)year and is limited to the workplan dated on the front page of this application. <br /> 8-29-02/MI <br /> ( <br /> _ �k <br />