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San Joaquin County Environmental Health Department Unit IV Well Permit Application Supplemental <br /> blow sda,�&I ^^��// <br /> NO <br /> JOB ADDRESS: (lnvrlaclZ�.�(, \ Y LLN Cf!' PERMIT SR# 6� <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 /> License #:p 7 O / <br /> FF 06 E xp Date: <br /> Date: ! _ Contractor: 1� ( lI , SII r/L• <br /> Signature: { �.�n n Title: <br /> Print Name:1./�p rs IV[JY W�( TVVAW <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: Q <br /> Carrier: '✓rtG Policy Number: c;;, <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 pro 'sions of Section 3700 of the <br /> Labor Code, I shall forthwith comply with those prov' <br /> Exp. Date: OV/D 9 / 09 <br /> I Signature: {, �l�n.,� <br /> Print Name: n � VIEtyP W, <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 AMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. <br /> RI ON F R OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> I l (sof C-57 licensed authorized representative), <br /> hereby a thorize(print name) SVI-eNY A T lignature i\i m� 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 /> 91291021MI <br /> EHD 29-01 1115107 WELL PERMIT APP <br />