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r Scan Joaquin County Environmental Health Depattrnent Unit IV Well hermit Application Supplement � <br /> JOBADDFtrzsB.21 Z I ovD u s 7-{(Lqz- b9, STDcKrdERMIT SRO. <br /> LICENSED CONTRACTORS DECLARATION (LCD <br /> I hereby affirm that I am licensed under the provtslons of Chapter 9(commeneft with Seuftn 7000)of Division <br /> 3 of the Swine"and Prof" s Code and my license Is h hull force and elect <br /> License £xpirstinn Date: <br /> Date: _ C�r: 11J <br /> Wgnature: r r d Title; �- f <br /> Printed Harris: ' i� tt___�•Y. <br /> WORKERS' COMPENSATION DECLARATION <br /> i <br /> I hereby affirm under penalty of penury one of the following declaratlon6: (CHECK ONE) <br /> _I have and will maintain a ce ific ale of c*nsetlt to self-insure for workers'compensation,as provided I& <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'compemz ftn Insurance,as rnquirad by SBcSon 3700 of the Labor Code, j <br /> Ill <br /> for t14s performance of the work for which this pbrniit is issued. MY wQrkeras'comperisation insurance i <br /> carrier and policy numbers are: ry <br /> Carrier. r t II LPolicyNumber_ I-w �M))tf <br /> i <br /> I certify that in the performance of the work for which this permit is Issuer!,I shall not employ any person in <br /> any manner so as to became subject to the wP*ers compensation laws of California,and agree that a I <br /> should become subjerk to the workers'compensation.provisions of Section 3700 of the Labor Cade,I shah <br /> forthwith comply with those provisions. <br /> f` irabon Date: Signature; i <br /> Printed Nwhe; <br /> I <br /> WARNING.FAIT.J"TO SECURE WORKERS*COMPENSATION COVERAGE IS UNLAWf AND SHALL SUBJECT j <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND Crib FINES UP TO ONE HUNDRED TWOUSAMD DOLLARS i <br /> ($100,000.),IN ADDITION TO TH9 CEHST OF COMPENSATION.INTEREST,ATTORNEY'S FEES,AND DAMAGES AS <br /> PROVIDED FOR IN aECTION 3700 OF THE LABOR CODE. <br /> AUT ORIZATION P R 2EM THAN C-57 SIGNING PERMIT APPLICATION <br /> I, f -j- (Wgnawm o!C47 Ilconsazd a zI1xwI od rePrazentativa), <br /> "mby authorkm(print narrw) <br /> to sign this San Joaquin County Well Permit Appllaatlon on my behalf. I understand this authorization is vattd for <br /> one(1)year and is Ilynhod to efts work plan died on ttra front page of this application. <br /> J!2!A2 f MI <br /> $gym-115�2-001 <br /> 9/30/2002 <br /> E© 39Vd DNI-1"II�1Q tl�R1 80966SE60Z T@:t%T LOLZ/S: 'eT <br />