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San Joaquin County Environmental Health Services,Unit IV Well Permit Application Supplement <br /> .�` - f�n 00-' ��� <br /> JOB ADDRESS:1 � PERMIT SR#: �— <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> 1 hereby affirm that I am licensed under the provisions of Chapter 9 (commencing with Section 7000)of Division <br /> 3 of the Business and Professions Code and my license is in full force and effect. 1 <br /> License y 1 J Expiration Date' <br /> Date- C, CO. Contractor: 7 £0 <br /> Signature: I Title: my�I Lam( <br /> Printed name: <br /> WORKERS' COMPENSATION DECLARATION l <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 consent 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 is issued. <br /> have and will maintain workers' compensation insurance,as required by Section 3700 of the Labor Cade, <br /> for the performance of the work for which this permit is issued. My workers'compensation insurance <br /> carrier and policy numbers are: <br /> 3 L C, <br /> ll-- �P (if L' 1 <br /> Carrier:c ��/� r� Policy Number: <br /> � T <br /> I certify that in the performance of the work for which this permit is issued, I shall not empicy 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 comply with those provisions. j <br /> i <br /> Date: �- "�'�J _Signature: <br /> Printed Name: <br /> WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL.AND SHALL SUBJECT I <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS f <br /> ($100,000.),IN ADDITION TO THE COST OF COMPENSATION,INTEREST,ATTORNEY'S FEES,AND DAMAGES AS <br /> PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. <br /> r- <br /> 1 P (C-57 licensed authorized representative),hereby <br /> authorize_ [� �kl{�C/ <br /> to sign Joaquin n this San Joa uin County Well Permit Application on my behalf. 1 understand this authorization is valid for 1 <br /> one(1)year and is limited to the work plan dated on the front page of this application. <br /> £d Wti6V:OT 0002 TO -daS 2886 828 60E : 'ON 3NOHd STSFleud oaaz punoao : WObd <br />