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San Joaquin County Environmental HealthDe artment <br /> 0,IV Well Permit Application Supplem4 <br /> Job Address: Permit SR#: <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> I hereby affirm that I am licensed under the provisions of Chapter 9 (commencing with Section 7000) of Division 3 of <br /> the Business and Professions Code and my license is in full force and effect. <br /> License#: Expiration Date: <br /> Contractor: Date: <br /> Signature: Title: <br /> Print Name: <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 for workers' compensation, as provided for by <br /> Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. <br /> ❑ I have and will maintain workers' compensation insurance, as required by Section 3700 of the Labor Code, for <br /> the performance of the work for which this permit is issued. My workers' compensation insurance carrier and <br /> policy numbers are: <br /> Carrier: Policy Number: <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 should <br /> become subject to the workers' compensation provisions of Section 3700 of the Labor Code,I shall forthwith <br /> comply with those provisions. <br /> Signature: Date: <br /> Print Name: <br /> Warning: Failure to secure workers' compensation coverage is unlawful,and shall subject an employer to criminal penalties and <br /> civil fines up to one hundred thousand dollars($100,000),in addition to the cost of compensation,interest,attorney fees, <br /> and damages as provided for in section 3706 of the Labor Code. <br /> AUTHORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> I, (signature of C-57 licensed authorized representative), <br /> hereby authorize (print name) , to sign this San Joaquin County <br /> Well Permit Application on my behalf I understand this authorization is valid for one (1)year and is limited to the <br /> work plan dated on the front page of this application. <br /> EHD 29-02-001 WELL PERMIT SITE <br />