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1� �_ I ,5 f) <br /> San Joaquin unty Environmental Health Department Unit IV Well Permit Appl tion Supplement <br /> JOB ADDRESS-7P/ Q / /ivy PERMIT SR#:r Al 35-6 T <br /> zzzt. i s . ~o to .35"a 7 <br /> LICENSED CONTRACTORS DECLARATIONL( CD) <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 aqA Prof ssions Code and my license is in full force and effect.. <br /> License tt: &19 Expiration Date: <br /> Date: Co tractor: <br /> Signature: Title: <br /> Printed name: <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 /> by 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' compen tion insurance, as required by Section 3700 of the Labor Code, <br /> for the performance of the work for whic is permit is issued. My workers'compensation insurance <br /> carrier and policy numbers are: 60-& (ff\.,Un <br /> Carrier: Policy Number: <br /> I certify that in the performance of the w rk for which this permit is issued, 1 shall not employ any person in <br /> any manner so as to become subject to he workers'compensation laws of California, and agree that if I <br /> should become subject to the workers'compensation provisions cf 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 3708 OF THE LABOR CODE. <br /> AUTHORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> 1, Z;tz /_ (Signa ofC-57 licensed authorized representative), <br /> hereby authorize(print name)_ &A, / ; rCA <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 /> 8-29-021 MI <br /> END 29-02-001 <br /> 6/22/04 <br />