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05/00/2004 08:50 2095e7aed33 FIFTH FLOORII` PAGE 03 <br /> i <br /> } <br /> San Joaquin County Environmental Health Department Unit IV Well Permit Application Supplement <br /> ' JOB ADDRESS: 5 a n PERMIT SR#: <br /> �rrd <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 <br /> 3 of the Business and <br /> Professions Code and my license Is in full force and effect. „ <br /> License tt: 1105 b 46'? Fxpiration Date:_l 13462 a� !i <br /> I <br /> rr <br /> Date: Y' Contractor. ( ,.�-✓1 -J� t°l <br /> Signature: Title: <br /> Printed 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 ofconsent to self-Insure for workers'oompensalion,as provided for <br /> by Section 3700of the Labor Code,for the performance of the work for which this permit is issued. <br /> ! 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 parmIt is Issued. Myworkers'compensation insurance <br /> carrier and policy numbers are; '! <br /> Carrier: /-Ilzt Policy Number: 7,42:W,0 ie Z <br /> 1 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 agr at If I <br /> should become subject to the workers'compens on provisions of Section 3700 of the LaborZodia, I shall <br /> forthwith Comply with those provisions. . <br /> i <br /> Expiration Data:*///01- Signature: <br /> Printed Name: <br /> WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT <br /> AN EMPLOYER TO CRIMINAL PENALMS AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> (0100,000.),IN ADDITION TO THE COST OF COMPENSATION,INTEREST,ATTORNEY'S FEES;AND DAMAGES AS <br /> PROVIDED FOR IN SECTION 3705 OF THE LABOR CODE. <br /> AUTHORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> I, (signature ore-87 licensed auth INeed representative), <br /> C�'v 1 <br /> hereby authorize(print name) J' r)r..n CLDLrf-eIC � <br /> tnsi n(hI son JoaQuih County well Permit Application on my <br /> behalf. I understand this authorization is valid for <br /> one(1)year and is limited to the work plan darted an the front page of this applicator. <br /> 849-021 Mi <br /> EHD 29.01.001 <br /> 91)0/1002 <br /> d 'd OOZE 1317d3SUI dH WH8D :OT i,00a b0 AHW <br /> d <br />