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VPs <br /> San Joaquin County Environmental Health Department Unit IV Well Permit Application Supplement <br /> JOB ADDRESS: (? 19 N. 4u,,_ PERMIT SR#: O 52 Z t- <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#: 6 3(�,_�, S 7 —Expiration Date: O 11 ,I r r <br /> --U C)-n <br /> Date: /10 jao0 Contractor: iPR& 5 ce ti L t N G (NC <br /> Signature: Title: <br /> Printed name: '� �� l��}LLAG EfFtZ – <br /> WORKERS' COMPENSATION 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 provided for <br /> bii 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'compensation insurance, as required by Section 3700 of the Labor Code, i <br /> for the performance of the work for which this permit is issued. My workers' compensation insurance <br /> carrier and policy numbers are:: <br /> Carrier: Z 11-3 T-1 1 r�1 <br /> ,,T" k L Policy Number: w::�_ 175 331c ° <br /> 1 wertify 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'compensation provisions of Section 3700 of the Labor Code, I shall <br /> forthwith comply with those provisions.6 <br /> Expiration Date: 30/01 Signature: <br /> Printed Name: <br /> WARtdING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> (51001000.),IN ADDITION TO THE COST OF COMPENSATION,INTEREST,ATTORNEY'S FEES,AND DAMAGES AS <br /> PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. <br /> AUTHORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> 1 _ (signature ofC-57 licensed authorized representative), <br /> hereby authorize(print name)_A I K iN c k- 4 <br /> to sign this San Joaquin County Well Permit Application on my behalf. I understand this authorization is valid for <br /> i <br /> one(1)year and is limited to the work plan dated on the front page of this application. <br /> 8-29-021 Ml <br /> L'HD 292-001 <br /> 6/22/04 <br /> Za/ZO 3smd ENI-IdNVS NOISI-3366 VZSbLEZOTS LZ:LT L09Z/OT/L© <br />