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04j08/20',12 MON 14:06 FAX (7]001 <br /> -saw, <br /> /f it <br /> San Joaquin County Environmontst Health Services,Unit.-IV Well Permit Application Sup,p(ement <br /> JOB ADDRESS- )1 d AJ' PERMIT Sly#: �`v3S9�7/I <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> I hereby affirm that I aryl licensed under the provisions of Chapter) (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#: /t9v 0 Expiration Date: <br /> Date: L O ontractor: <br /> Signature: c Title: <br /> Printed name: Joel l V I n_/ _. <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the following declarations: (CHECK ALL THAT APPLY) <br /> I have and will maintain a certificate of oonsernt to self-insure for workers' compensation, as provided for by <br /> `Section 3700 of the Labor Code,for the performance of the work for which this permit Ls issued. <br /> I have and will maintain workers'compensation insurance, as required by Section 3700 or 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: a 1.o-) l Policy Number: <br /> certify 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 co ply with those provisions. <br /> Date: Signature: -1 <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 /> ($100,000.),IN ADDITION TO THE COST OF COMPENSATION, INTEREST,ATTORNEY'S F1=ES,AND DAMAGES As <br /> PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. <br /> 1li�,ccresed a orizaa presentativc), hereby <br /> /jA <br /> authorize > ✓ G% ��G' �./ C� <br /> to 6ign this Satz Joaquin County Well PennitAppiiccat on on my Behalf. I understand this authorization is valid fov <br /> one(1)year and is limited to the work plan dated on the front page of this application_ <br /> F '�i I'IUcI� Nv7s'0 l E-if-,F,I- Pe-C'1 t <br />