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San Joaquin County Environmental Health Department Unit IV Well Permit Application Supplement <br /> JOB ADDRESS; PERMIT SRW. <br /> `b <br /> LICENSED CONTRACTORS DECLARATION (LCD <br /> I hereby affirm that I am licensed under the provisions of Chapters(commencing with Section 7000) of Division <br /> 3 of the Business_and Professioo�ns�Code and my license is in full force and effect. <br /> Ucanse#-� �a�_�__ Expiration Dale: d <br /> �, <br /> Date: CContractor � Z�tf <br /> SiOnatura: t Title: v� <br /> Printed name; <br /> WORKERS' COMPENSATION OF-CLARATION <br /> I hereby.affirm under penalty of perjury one of the following dederatlons: (CHECK ONE) <br /> I 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'compensatior:insurance,as required by Section 3700 of the tabor Code, <br /> for the performanceof the work for which this permit is issued. My workers'compensation insurance <br /> carrier and policy Numbers are: _ <br /> Carrier-, _ � Policy Number-, <br /> I cer'tlfy that in the performance of the work for which this permit is issued, I shatl not employ any person in 1 <br /> any manner so as to become Subject to the workers'romponsation laws of California, and agree that If I <br /> should become subiecl to the workers'compansatian provisions of Section 3700 of the Labor Code,.1 shall <br /> forthwith comply with those provisions. <br /> oatie: Signature: <br /> Printed Nasse: <br /> WARNING:FAILURE TO SECURE WORKERS'COMPEN;ATION COVERAGE 13 UNLAWFUL,ANtYSHALL SUBJECT <br /> AN EMPLOYER TO CRIIUiiNAL PENALTTES AND CIVIL FINES LIP TO ONE HUNDRED THOUSAND DOLLARS <br /> (5100,000.),IN ADDITION TO THE COST OF COMPENSATION,INTEREST,ATTORNEY'S FEES,AND DAMAGES AS <br /> PROVIDED FOR IN SECTION 3708 OF THE LABOR CODE. <br /> AUTHORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> 1, (signature ofC-57 ticanved authorized representbtive), <br /> herebyaut;hori:e(peintname) � <br /> to sign this San Joaquin County Well Permit Applicatlon on my behalf. I undarsstand this authori.lation is,valid t°or <br /> one(1)year and Is limited to the wark plan dated on the front page of this appHcallon. <br /> 0-29-021 MI <br />