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I San Joaquin County Environmental Health Services, Unit IV Well Permit Application Supplement JOB ADDRESS : �e�`� Maw (�CC� PERMIT SR#: LICENSED CONTRACTORS DECLARATION (LCD) 1 hereby affirm that I am licensed under the provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business 1 annd Professions Code and my license is in full force and effect. } License #: 7c,' 0701 11Expiration Date: 43q 00 Date: 1 00 Contractor: \bwar .I') C Signature: Title: "tct LeAll Printed name: Jodu VI L&lZ1 WORKERS' COMPENSATION DECLARATION I hereby affirm under penalty of perjury one of the following declarations: (CHECK ALL THAT APPLY) _ I have and will maintain a certificate of consent to self-insure for workers' compensation, as provided for by Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. V1 1 have and will maintain workers' compensation insurance , as required by Section 3700 of the Labor Code, for the performance of the work for which this permit is issued . My workers' compensation insurance carrier and policy numbers are: Carrier: _�� Fagln Policy Number: I UWL5g4� 55 Z-05 _ I certify that in the performance of the work for which this permit is issued , I shall not employ any person in any manner so as to become subject to the workers' compensation laws of California, and agree that if I should become subject to the workers' compensation provisions of Section 3700 of the Labor Code, I shall forthwith comply with those provisions, /l Date: j C) Signature: Lf • / Printed Name: L i L WARNING : FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS ($100,000. )3 IN ADDITION TO THE COST OF COMPENSATION, INTEREST, ATTORNEY'S FEES, AND DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. 15 � 47 (C-57 licensed authorized representative), hereby authorize to sign this San Joaquin County Well Permit Application on my behalf. I understand this authorization is valid for one (1 ) year and is limited to the work plan dated on the front page of this application.