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z <br /> San Joaquin County Environmental Health Department Unit IV Well Permit Application Supplemental <br /> JOB ADDRESS: PERMIT SR# <br /> LICENSED CONTRACTORS. DECLARATION (LD) <br /> I hereby affirm that l am licensed under the provisions of Chapter 9(commencing with Section 7000) of <br /> Division 3 of the Business and Professions Code and my license is in full force and eled. <br /> License.#: 9 a 0 9 04:: Ex Date: /S)o <br /> Date: �•V-Db Contractor: <br /> Signature: Title: cjll�Y !`7'� <br /> tt <br /> Print Name: 1r'"T' t <br /> WORKER'S COMPENSA N DECLARATION <br /> I hereby affirm under penalty of perjury one of the following declarations: (check one). <br /> I have and will maintain a certificate of consent to self-insure for workers'compensation, as <br /> provided for by section 3700 of the labor Code, for the performance of the work for which this <br /> permit is issued. <br /> I have and will maintain workers'compensation insurance, as required by Section 3700 of the <br /> Labor Code,for the performance of the work for which this permit Is Issued. My workers' <br /> compensation insurance Carrie and policy numbers are: <br /> Carrier: Policy Number. ` <br /> I certify that in the performance of the work for which this permit is issued, I shall not employ any <br /> .person in any manner so as to become subject to the workers'compensation law of California,and <br /> agree that if l should become subject to workers'compensation provisions of Section 3700 of the <br /> Labor Code, I shall forthwith comply with those provis s. , <br /> Exp. Da*:_ � 2 Signature: <br /> Print Name• ?Dbcr4— y ) <br /> — I <br /> WARNING:FAILURE TO SECURE WORKER$'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT AN EMPLOYER TO <br /> CRIMINAL PENALTIES AND CIVIL PINES UP TO$100,000,IN ADDITION TO THE COST OF COMPENSATION,INTEREST, <br /> ATTORNEY'S FEES,AND DAMAGES AS PROVIDED FOR IN SECTION 3709 OF THE LABOR CODE. <br /> OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> 1, (signature of C-67 licensed authorized representative), <br /> hereby authorize(print name) .to <br /> sign this San Joaquin county Well Permit Application on my behalf. I understand this authorization Is valid <br /> for one year and Is limited to the work plan dated on the front page of this application. <br /> 8l79f0?JMI <br /> FI-02(k01 11/,07 WZU.PERMT APP <br /> E0/E0 39ti8 SNI71I6a M?A 809669£602 SE:80 800Z/ZZ/90 <br />