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San Joaquin County Environmental"Ca th Department Unit N Well Permit Application Su <br /> JOB ADDRESS: pf� n�l <br /> PERMIT SR <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> 1 hereby affirm that I am licensed under the provisions of Chapter 9(commencing with Section 7i]Op)of <br /> Division 3 of the Business and Professions Code and my license is in full force and e <br /> License# to O 904— 2 <br /> E ,Djate: <br /> Date: Contractor, ?� Ynr . <br /> t <br /> Signature <br /> Title: <br /> Print Name: <br /> WORKER'S COMPENSA N DECLARATION <br /> I hereby affirm under penalty of perjury one of the following declarations:(check one) <br /> 1 have and wilt maintain a cerlifrcate of consent to selfinsure for workers'compensation,as <br /> provided for by section 3700 of the tabor Code,forthe perkwrnance of the work for which this <br /> permit is issued. <br /> I have and will maintain workers,compensation insurance,as requiredSectio <br /> n 3700 o <br /> Labor Code,for the performance of the work for which this permit Is issued. My workers'f the <br /> compensation insuranE� PINceari <br /> ce and policy numbers are: <br /> Carrier.%'-� Policy Number. t� '^ U) <br /> i certify that in the Pince of the work for which this permit is issued, i shall not e <br /> person in any manner so as to employ any <br /> became subject to the womicers'compensation law of California,and _ <br /> agree that if t should become subject to workers'Compensation provisions of Section 3700 of the <br /> Labor Code, I shall forthwith Comply with those p <br /> Exp.Date: Signature: Iwr�r�,,�� <br /> Print Name. � V)L <br /> WA :FAILURE To SECURE WORKOW COMPENSATION CflYERAR3E IS UNLAWFUL,AND SHALL SUdI£CT AN EMPLOYER TO <br /> CRIMMAL FENALTI AND CML FIM Ur TO X100,000,Ur ADDrnoN To TM Coal DF COM PENSATioN,INTEREST, <br /> ATTORWft FEES„AND DAMAGES As PROVIDED FoR IN SECTION 370 OF THE LAaiOR COW- <br /> O R OTHER THAN C-67 SIGNING PERMIT APPLICATION <br /> (signature of C,.87 licensed autlwniz d <br /> hereauthorize mel, <br /> by (print name) ld s cc Eta k'v w 1-7- to <br /> Big"this San Joaquin county Weil Permit ARMcation-on my behalf. I understand this audwrbation is valid <br /> for one year and Is lin ked to tate weak plan dated on the front page of'this application. <br /> Bra10= <br /> EN02041 114ar <br /> VML PMWT ova <br />