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• <br /> NP- <br /> San <br /> / ,t <br /> Joaquin County Environmental Health Department Unit IV Well PermitApplicationSupplemental <br /> JOB ADDRESS: 502 C. rbNEera-r I PERMITSR# X 605 <br /> Tm-c;G4 <br /> LICENSED CONTRACTORS DECLARATION {LCD} <br /> I hereby affirm that I am licensed under the provisions of Chapter 9(cc mmend Ing with Section 7000)of <br /> Division 3 of the Business and Professions Code and my license is in full force and effect. <br /> License* 71,o 0't 4 Exp Date: 01-3I-2da9 <br /> Date: QS 28-AS Contractor: [,daaomAb M A & r'&[.6214; A/C, <br /> Signature: �E Ldfba lato( Title: Po&. SiDr-trr <br /> Print Name Co AiC€,yCf _E, IArJrSDMaAAa <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 /> compensation insurance carrier and policy numbers are: <br /> Carrier: fddL} Policy Number: 00?6ZU-a607 <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. Data: 10 12,e08 Signature: eZalerst.a �G. GJo7W ✓2ZAJ <br /> Print Name: CeAvCwi/ , 6. V"aOaA" <br /> WARN VNG:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT AN EMPLOYER TO <br /> CRIMINAL PENALTIES AND CML 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 /> AUTHORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> CoAzc r " g�, L<LMM!Hrm - ( (signature of C-57 licensed authorized representative), <br /> hereby authorize(print name) *rRyim" RGdua ,to <br /> sign 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 /> anarotiMl <br /> EiG 2PC'I '1^.fV`Y <br /> N'ELl12PNli+P' <br />