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San Joaquin Coutity Environmental Health Department Unit IV Well Permit Application Supplement <br /> JOB ADDRESS: Q/try PERMIT SR#: <br /> 0*4 Ft o us Q 6 ems' _ � C— <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. y <br /> License#: ( _S Expiration Date: �/ 3 1 A) <br /> Date: Contractor: �c P 0-11 <br /> Signature: c�— Title:. /G <br /> Printed name: j' <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 self-insure for workers' compensation,as provided for <br /> ty"Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. <br /> I 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 pollircy'nuumbe are: <br /> Carrier: uA�y J� �L i-�f Policy Number: 2��% y� -71-73 <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: 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 3706 OF THE LABOR CODE. <br /> AUTHORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> 1, yt (signature ofC-57 licensed authorized representative), <br /> hereby authorize(print name) . eIt <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. f 'Y S 5`�Ilk I <br /> 8-29-02 J Ml ` <br /> FHD 29-02-001 <br /> 6/22/04 <br /> a 'd Xd3 131'N3Sd3 dH WUtE :OT 9000 f,0 400 <br />