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�3 <br /> u _ ,�r <br /> ►� 2g.S 1 <br /> San Joaquin County Environmental Health Department Unit IV Well Permit Application Supplement <br /> .JOB ADDRESS: ICP5 lati Hie iciin(Igio4, fA PERMIT SR#: D <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> 1 hereby affirm that I am licensed under the provisions of Chapter 9(com �wfthtion 7000)of Division <br /> 3 of the Business and Professions Code and my license is in ful d effect. <br /> License#: 445'-t'fi 7> ion Date: t I Z0 i Q_ <br /> Hate: n r: <br /> Signature: Title: <br /> Printed name: ca< Iv� P <br /> WORKERS' COMPENSATION 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 self4naure for workers' ensation,as provided for <br /> by Section 3700 of the Labor Code,for the performance of the work f 1ch this permit is issued, <br /> have and will maintain workers'compensation insurance, uired by Section 3700 of the Labor Code, <br /> for the performance of the work for which this permit is ' ed. My workers' compensation insurance <br /> carrier and policy numbers are: <br /> Carrier: f� Policy Number: l 13 S� <br /> I certify that in the performance of work for which this permit is issued, I shall not employ any person in <br /> any manner so as to become s to the workers'compensation laws of California, and agree that If I <br /> should become subject to t orkers'compensation provisions of Section 3700 of the labor Code, I shall <br /> forthwith comply with th provisions. <br /> Expiration 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 /> ($100,000.),IN ADDITION TO THE COST OF COMPENSATION,INTEREST,ATTORNEY'S FEES,AND DAMAGES AS <br /> PROVIDED FOR IN SECTION 3705 OF THE LABOR CODE. <br /> AUTHORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> (signature ofC-57 licensed authorized representative), <br /> hereby authorize(print name) + <br /> to sign this San Joaquin County Weil Permit Application on my behalf. I understand this authorization is valid for <br /> one(1)year and Is limited to the work plan dated on tate front page of this application. <br /> 8-29-02 1 MI <br /> EHD 29-02-001 <br /> 6/22/04 <br />