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i <br /> San Joaquin County Environmental Health Department Unit IV Well Permit Application supplement <br /> JOB ADDRESS; c c� PERMIT $R#: <br /> 'PC.tC f T r,— k V <br /> LICENSED CONTRACTORS DECLARATION I.CD <br /> I hereby DMrm that I am licensed under the provisions of Chapter 9(commencing with Section 7000)of Division <br /> 3 of the Business anfj <br /> and Profess- Code and my license is in full force and ect, <br /> L-cense#: Ci V 1 Expin3tionnDate' <br /> Dote. Co ra r• 7✓����} f t� 0 if <br /> Signature• <br /> Title: <br /> Printed name: i] _„y'^f , '( <br /> WORKERS'COMPENSATION DECLARATION <br /> I hereby affirm under penally of perjury one of the following declaratlons: (CHECK ONE) <br /> —11166 and will maintain a Certificate of consent to Self-insure for as provided for <br /> pensa <br /> wwkeitm-comti <br /> on, <br /> by Section 3700 Of the Labor Code,for the performance of the work for which this permiton IS issue, <br /> I have and will maintain workers'Compensation insurance,as required by Section 3740 of the Lebor Code, <br /> for the perfgmmncs of the work for which this permit Is Issued. My workers'compensation insurance <br /> carrier and policy numbers are: <br /> CarrierTC�- Policy Number <br /> I certify that in the performance of the Work for which this permit is issued,I shag not employ any.pe mon in <br /> any manner so as to become subject to the workers'compensation laws of Calftmia,and agree that if I <br /> should become sub,jed to the workers,compensation provisions of Sec ion 3700 of the Labor Code,I shall <br /> forthwith Comply with those provisions. , <br /> Exp-ration Date: /Q Signature: <br /> Printed Name; <br /> WARNING:FAtt.URE to SECURE WORKERS,CO ENSATION COVERAGE m UN UWE AND SHALL SUt3JtGCT <br /> AN EMPLOYER To CRIMINAL PENALTIES AND CIVIL FINE$UP TO ONE HUNvnED 17lOUSAND DOLLARs <br /> ($1140,000.),IN ADDITION TO THE COST OF COMPENSATION,INTEREST,ATTO�t-y�S FEES,AND DAMAGES AS <br /> PROVIDED FOR IN sECMN 37go OF THE LABOR CODE, <br /> AUT ORIZATION F R QW-8 THAN C.57 SIGNING PERMIT APPLICATION <br /> • 1. � it/ . <br /> t$tenature OM47,11oansed authorized representative), <br /> h rift authorhe(print name) xt C✓ <br /> to Man this tion Joaquin County Well Permit Application an try behalf, i underatend thts aluthorization is valid for <br /> ono(1)year and Is Limited to the work plan dated on the front Pegg of this spplication. <br /> 049 1 MI <br /> EHD 29�2-dor <br /> 91302002 <br />