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_-_- _-- _. 4002 <br /> wu <br /> tl <br /> Unit.IV lilfeU Permit ApRlicatent <br /> San Joaquin County Environmenttal,Kealth Services, T <br /> JOB ADDRESS: Z" N , : YY1G;.r PERMIT St : <br /> �ar�e CA <br /> 0 <br /> LICENSED CONTRACTORS DECLARATION WC-D) <br /> I hereby affirm that 1 am licensed tinder the provisions of Chapter 0 (commencing with Section 7000;of Division <br /> 3 of the Busin�e/sns and Professions Gode and my license is to full force and effect. <br /> License#' /c����y _Expiration Date: <br /> Date: — <br /> - <br /> "itle: - — <br /> Signature: - <br /> Printed name, J-0 <br /> WORKERS'.COMPENSATION DECLARATION <br /> I heroby affirm under penalty of perjury one of the following declarations; (CHECK ALL THAT APPLY) <br /> I have and will maintain n certificate of consent to self-insure for workers' compensation, as Provided for by <br /> Section 3700-of the Labor Code, for the performance or 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, <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: <br /> CI.C�i _ Policy Number• _ 3 :(/ <br /> _I certify that in the performance of the work for which this permit is issued, 1 shall not employ any person in <br /> any manner so as to become subject to the workers' compensation laws of California, and agree th tit L <br /> u <br /> on_3700 of the Labor Gode, I shall <br /> should become suojectto the workers'compensation provisions of Sg�` <br /> forthwith Comply%vith those provisions. <br /> Date: <br /> 3 O`�' Signature: <br /> Printed Name:— �- Iti� <br /> WARNING: FAILURE.TO SECURE WORKERS'coMPENSAT10tJ COVERAGE IS UNLAWFUL,AND SHALL SUBJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> PROVIDED FOR NSATION, INTEREST,ATTORNEY'S FEES,AND DAMAGES AS <br /> FORN SECTION 3706 Op THE t.A <br /> (C 57 ensed author izad representative), hereby <br /> authorize <br /> to sign this San Joaquin County Well Permit Application on my tsehalf. I understand this au-Jlorization'i:+valid fof <br /> ear and 4s limited to the work plan dated on the front page of tl�ts application. �-- <br /> Lone(I)Y_.._ — <br />