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{' i .. <br /> San Joaquin County Environmental!Health Department'Unit IV Well Permit Application Supplement <br /> JOB ADDRESS: �S � PERMIT SR#: 3 � ' <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> » <br /> I hereby affirm that I am licensed under the provisions of Chapter 9 (commencing with Section 7000)of Division <br /> f 3 of the <br /> I Business and Prof <br />� essEons Code and my license is in full force and effect. <br /> License#: cs 7 Exp Date: <br /> Date: Contractor: ` ? <br /> - 1; <br /> ddr <br /> Signature: €) Title: I 1w, f <br /> k4 <br /> Printed name: i :' ii <br /> WORKERS;' 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 for4 rkers' 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 /> -,KI 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: ��l�/� Policy Number:2 /4441 C! 90 Z/7_ <br /> i <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; !: i <br /> ii <br /> Expiration Date. _ __Signature: <br /> �Izr `/ _ <br /> tinted Name:_�11� <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 /> ($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 /> Er I <br /> AUTHORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> _(signatureLC-57 licensed authorized representative), <br /> hereby authorize(print name) <br /> N. I� <br /> to sign this San Joaquin County Well Permit Application on my behalf. Iyy understand this authorization is valid for <br /> one(1)year and is limited to the work plan dated on the front page of this application. <br /> ,l <br /> 8-29-021 MI '1 <br /> EHD 29-02-001 i <br /> 9/30/2002 <br />