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I <br /> Z <br /> San Joaquin County Environmental Health Department Unit IV Well Permit Application Supplemental <br /> JOB ADDRESS: <br /> '] FY� E- �i _ 7 S 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 effect. <br /> (j�I Ex I �I ' <br /> License#: — (pDate:` l <br /> Date: 1� (� Contractor. <br /> Signature: Title: 0 Mu`U Y1 (I <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 If <br /> provided for by section 3700 of the labor Cade, 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 /> compensation insurance carrier and policy numbers are: <br /> Carrier: Policy Policy Number: <br /> I certify that in the performance of the work for which this permit is issued, I shall not employ any <br /> i 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: I I� Signature: (' �\ <br /> at2anr=� <br /> Print Name: C1�Is�u� l" ���✓)�� <br /> S <br /> WARNING: FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT AN EMPLOYER TO <br /> CRIMINAL PENALTIES AND CIVIL FINES UP 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 /> ZAF1 FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> I, (signature of C-57 licensed authorized representative), <br /> hereby authorize (print name) ✓T/C/c/[y �I' 5— CLQ ,to <br /> sign this San Joaquin county Well Permit App (cation 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 /> R129102/MI <br /> E1103?01 tV5M1 WELLPERMRAPP <br />