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San Joaquin County Environmental Health epartment Unit IV Well Permit Application Supplement <br /> JOB ADDRESS_ ZL� ?A-1;,L– PERMIT SR#: 451135 <br /> �� Sw <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> I 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.. <br /> License#: 8 ) C1 5 0 Expiration Date: <br /> Dale: 6912-2-16 7 Contract r. <br /> Signature: Title_ W 6A1_ Lf'Zt <br /> Printed name: i c <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the following declarations: (CHECK ONE) <br /> LI-11I have and will maintain a certificate of consent to self-insure for workers'compensation, as provided for <br /> by 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 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: ZU2tCH +N"t0(2KA 1J fNS• �c)• Policy Number. wl_9 z5�61�ss o <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 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. <br /> Expiration Date: �I 2c* Signatur <br /> Printed ame: ` V-4— <br /> WARNING: <br /> � <br /> WARNING:FAILURE TO SECURE WORK MPENSATION COVERAGE IS U UL,AND SHALL SUBJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES RED THOUSAND DOLLARS <br /> (5100,000.),IN ADDITION TO THE COS F COMPENSATION,INTEREST,ATTORNEY'S FEES,AND DAMAGES AS <br /> PROVIDED FOR IN SEC�NFOR <br /> THE:LABOR CODE. <br /> ALITHORIZA OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> 1, r (signature ofC-57 licensed authorized representative), <br /> t <br /> hereby authorize(print name) 3 � <br /> to sign this San Joaquin County Well 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 the front page of this application. <br /> 0-29-021 MI <br /> 141(1)29-112-MI <br />