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San Joaquin County Environmental Health Department Unit IV Well Permit Application Supplement <br /> JOB ADDRESS: 1400Ipe" e � t�v PERMIT SR#: 105358 2 <br /> fdd t- o f 5�ock* <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> I hereby affirm that I am licensed under the provisions of Chapter 9(commencing with Section 7000)of Division <br /> 3 of the Business and Professions Code and my license is in full force and effect. <br /> License#: 5M2. 3�4 Expiration Date: 12 15 j 1 I 6 <br /> Date: V --mon actor. � -DY I l t. <br /> (,L..SignatuTitle: , <br /> Printed name: U)t)IJ uoi��i, C-L-� <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the following declarations: ECHECK ONE) <br /> _I have and will maintain a certificate of consent to self-insure for workers'coP Sensation,as provided for <br /> by Section 3700 of the Labor Code,for the performance of the work for which this permit is issued. <br /> �Q 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. 0 y workers'compensation insurance <br /> carrier and policy numbers are: <br /> Carrier: Policy Number: <br /> I certify that in the performance 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 laws of California,and agree that if I <br /> should become subject to the workers'comperisation provisions of Sectio 3700 of the Labor Cade, I shall <br /> forthwith comply with those provisions. �l <br /> Expiration Date: L J Signature:6� A <br /> Printed Name: D60 r L C1 <br /> WARNING:FAILURE TO SECURE: ORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> QNIMIM4Mj,IN ADDITION TO THE COST OF COMPENSATION,INTEREST,ATTORNEY'S)EES,AND DAMAGES AS <br /> PROVIDED FOR IN SECTION PTM3OF THE LABOR CODEK <br /> AUTH RIZA IOf��N FOR- THER T N C-57 SIGNING PERMIT APPLICATION <br /> 1, signature ofC-57 licensed authorized representative), <br /> hereby authorize(print name) , <br /> to sign this San Joaquin County Well Permit Application on my 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 /> U-29-02/Mf <br /> E}ID 29-02-001 <br /> 6(22AN <br />