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d—)L42 4o,07— <br /> Oak <br /> o,07—Ci'1^" <br /> San Joaquin Countynvironmenta�ith Department Unit IV Well Permit Application Supplemental <br /> I JOB ADDRESS: PERMIT SR# es/li5 7 <br /> c�s�) <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> 1 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 /> License#: I Exp Data: <br /> � <br /> Date: �fl Contractor: `-1 V <br /> Signature: (� Title: \ 11 k Y <br /> Print Name: `�� ]wr Y tit✓1� <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: nn�rr^ <br /> Carrier: �q�flyll� Policy Number: �U2-V/1 <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, II shall forthwith comply with those provisionsAdg <br /> Exp. Date:_ ( `2 (�1D Signature: �— <br /> Print Name: <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 /> TION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> ,, ti« (signature of C-57 licensed authorized representative), <br /> hereby authorize(print name) <br /> Sllv,n t� � y� �Cd� A to <br /> sign this San Joaquin county Well Permlt 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 /> i <br /> 8/29102/MI <br /> WELL PERMIT APP <br /> EHD 23-01 11/5/07 <br />