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hcation Supplement <br /> San Joaquin County Envlronmentai He Ith Departure Unit IV Wall ermit App <br /> J06 ADDRESS: <br /> PERMIT SR#: <br /> /9'023 Ir s• <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> I hereby affirm that I am licensed under the provisions of Chapter 0(commencing with Section 7000)of Division <br /> 3 of the Business and Professi ns Code and my license is in full force and e ect- 11) E' <br /> License#: V�i Expiration Date: ' <br /> Co dor <br /> flats: � <br /> T <br /> signature: itle: <br /> Printed n2me: -20K+ � <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the following declarations, (CHECK ONE) <br /> _1 have and will maintain a certificate of consent to self-insure for workers'compensation, as provided for <br /> by 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• <br /> for the performance of the work for which this permit is issued. Arty workers'compensation insurance <br /> carrier and policy numbers are: / f <br /> Carrier. J <br /> (i i-ol-�f V�)r) Policy Number. <br /> I certify that in the peffoimance 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 satin cs offion 3700 California, <br /> the and <br /> agree Cods I shalt <br /> should become subject to the workers`compen P <br /> forthwith comply with e provisions- r <br /> EacpirafJoo Date- 1ffa Signature.• /f <br /> Printed Name: � r�' i <br /> WARNING:FAILURE TO SECURE WORKERS'COME FINES UP TO ONTION �IIN UNLAWF THOUSAND DOLLARS AN EMPLOYER TO CRIMINAL PENALTIES AND <br /> (E1oo,000_),IN ADDITION TO THE COST OF COMPENSATION,INTEREST,ATTORNEY'S FEES,AND DAMAGES AS <br /> PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. <br /> AUT ORIZATION F R 0 THAN C-57 SIGNING PERMIT APPLICATION <br /> fl � <br /> (signature 9f�-571ic®nsed authorized representative), <br /> I, <br /> hereby authorize(print name) <br /> cc <br /> to sign this San Joaquin County Well Penult Application on clay behalf. I understand this authorization is valid for <br /> one(1)year and Is limited to the work plan dated on the front page Of this application. <br /> 8-29421 MI <br /> EffD-29 o2-001 <br /> 9/30/2002 <br /> ZO 39Vd <br /> JNIIIIJQ WSA 50966966aZ b0:VT L0aZITEIL0 <br />