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San Joaquin County Environmental Health Department Unit IV Well Permit Application Supplemental <br /> JOB ADDRESS: W NWX S`r PERMIT SR # <br /> Sfio l< 7rl50 I CXR <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 #: of 1G 3q (r) S Exp Date : 1 " 3I PDQ <br /> Date: 9 'o15'd / Contractor: 1 if)c - � I.LIApCr <br /> Signature: -- l Title: nco- ' <br /> Print Name: 1. DVI L) i; cYk4 <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�Tf insurance carrier and policy numbers are: I q <br /> Carrier: 0) 0 Policy Number: rJ 1' r, Q I <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, 1 shall forthwith comply with those provisions . <br /> �y <br /> Exp. Date: 0o Signature: 4a>' 9 <br /> Print Name: �V {T <br /> WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL SUBJECT AN EMPLOYER TO <br /> CRIMINAL PENALTIES AND CIVIL RHES UP TO $100,0005 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 /> 4rU1 iORIZATPN OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> (signature of C-57 licensed authorized representative), <br /> hereby authorize (print name) M i C )f FL CNENDoRi� (J) �y F 4DW E LL �j /�oL to <br /> j 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 /> 81291021MI <br /> END 29-01 Ii/51R7 WELL PERMIT APP <br />