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1002 <br /> -mew <br /> R> <br /> San Joaquin County Envirortmental Kealth Services,Unit.IV Well Permit ApplicationSk3.ppl`,rnent <br /> JOB ADDRESS: Z'I ° 1`�"���� S� pERltlElT SF;ifi: le vt <00;f;5�E: <br /> LICENSED CONTRACTORS DECLARAT)ON (LCD) <br /> 1 hereby affirm that 1 dni licensed under the provisions of Chapter 0 (commencing with Section 7000;of Division <br /> 3 of the Businrees55 and Professions Gode and my license is to full force and effect. <br /> License#: /c� Expiration Date: <br /> Date: <br /> Signature' Title: - <br /> Printed name: <br /> WORKERS' COMPENSATION DECLARATION <br /> I hero:by affirm under penalty of perjury one of the following declarations; (CHECK ALL THAT APPLY) <br /> I have and will maintain a certificate of consent to self-insure for workers' compensation, as provided for by <br /> ~Section 3700 of the Labor Codc, for the performance or the work for which this permit is Issued. <br /> 'i/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: Policy Num4er: <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 mannsr so as to become subje4ct to the workers' compensation laws of California, and agrea that it I <br /> should become subject to the workers'compensation provisions of Sion 3700 of the Labor Code, I shall <br /> forthwith comply with those provisions. f <br /> � I3 jp� , <br /> Date' Signature:_ <br /> Printed Name' <br /> WARNING: 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 /> ($I00,000.), IN ADDITION TO THE COST OF COMPENSATION, INTEREST,AcTTC?RNEY'S FEES,AND DAMAGES AS <br /> PROVIDED FOR IN SECTION 3706 Or-THE LABOR CODE. <br /> en�se'd authorized representative), hereby <br /> autFmrize <br /> to sign this San Joaquin County Well Permit Application on my behalf, I understand this authorization iq valid for <br /> one(1)year and is limited to the worl<plan slated on the front page of this application_ <br />