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San Joaquin County Envir iental Health Department Unit N Well Pe.-nit Application Supplemental <br /> JOB ADDRESS: _ l <br /> 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 <br /> Division 3 of the Business and Professions Code and my license is in full force and e <br /> License#: 4 a O <br /> Exp Date: <br /> Date: '� tI Contractor: <br /> Signature: C-777- <br /> 'Z <br /> Title: )—}.--- <br /> Print Name: ?ri v'( 01 J <br /> WORKER'S COMPENSA N 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 b <br /> Labor Code, for the performance of the work for which this permit is issued.My wo3 k0ers ' the <br /> compensations insurance Carrie and policy numbers are: <br /> Carrier: % � � polis Num Q2QLLq__LL_ <br /> y ter: t1 1 <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 l should become subject to workers' compensation provisions of Section 3700 of the <br /> Labor Code, 1 sh II forthwith comply with those provi ' ns. <br /> Exp. Date: Signature: <br /> Print Name: rbbflr-_ V 1 L <br /> WARNING:FAILURE TO SECURE WORKERS'CORVENSATION COVERAGE IS UNLAWFUL,,AND <br /> CRIMINAL PENALTIES AND CML FINES UP TO$100,000,1 SHALL SUBJECT AN EMPLOYER TO <br /> ADDmON TO THE COST OF COMPENSATION,INTEREST, <br /> ATTORNEY'S FEES,AND DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. <br /> 1, <br /> //APT"OR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> (si na of C�7 ticens uthor¢ed representative), <br /> hereby authorize(print name) � r <br /> sign this San Joaquin county Well P 'to <br /> Application my behalf. I understand this authorization is valid <br /> for one year and is limited to the worms plan dated on the front page of this applicatlon. <br /> &2M2111111 <br /> E K0 2U l 1115,07 <br /> WELL PERMIT APP <br />