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San Joaquin County Environmental Health Department Unit IV Well Permit Application Cationn Supplemental I i <br /> JOB ADDRESS: 22Zs'O I S- PE RMIT SR# 65l 6 53 I` <br /> I . <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> in with Section 7000 of <br /> I hereby affirm that I am licensed under the provisions of Chapter 9 (commencing ) I <br /> Division 3 of the Business and Professions Code and my license is in full force and effect. <br /> License#: gg51 Exp Date: <br /> 619-01b - ay C v��9 <br /> Date: Contractor: <br /> Signature: Title: <br /> Print Name: t s;' Z1�V(y1-&r I <br /> WORKER'S 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 <br /> provided for by section 3700 of the labor Code,for the performance of the work for which this <br /> permit Is Issued. <br /> I have and will maintain workers'compensation insurance, as required by Section 3700 of the i <br /> Labor Code,for the performance of the work for which this permit is issued. My workers' <br /> compensation insurance carrier and policy numbers are: <br /> Carrier: �� _ Policy Number: 1p�0�1� <br /> I certify that in the performance of the work for which this permit is issued, I shall not employ any <br /> person in any manner so as to become subject to the workers'compensation law of Califomia, and i <br /> agree that if I should become subject to workers' compensation provisions of Section 3700 of the <br /> Labor Code, I shall forthwith comply with those provisions. <br /> Exp. Date: g�i � Signature: <br /> Print Name: <br /> WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT AN EMPLOYER TO <br /> CRIMINAL PENALTIES AND CIVIL FINES UP TO$100,000,IN ADDITION TO THE COST OF COMPENSATION,INTEREST, <br /> ATTORNEY'S FEES,AND DAMAGES AS PROVIDED FOR.IN SECTION 3706 OF THE LABOR CODE. <br /> N FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> (signature of C-57 licensed authorized representative), i <br /> hereby au orize(print name) r��'/++ 1U 06 to <br /> sign this San Joaquin county Well Permit Application on my behalf. I understand this authorization is valid <br /> for one year and Is limited to the work plan dated on the front page of this application. <br /> I <br /> 13129102JMI <br /> EHD 28-01 111W7 WELL PERMIT APP <br />