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s 6� v <br /> San Joaquin County Environmental Health Department Unit IV Well Per <br /> C�'co/n dO•`�� Not K- it Application Supplemental <br /> C <br /> JOB ADDRESS: P pQ <br /> a �'y °Yy �far PERMIT SR# <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> I hereby affirm that I am licensed under the provisions of Chapter 9(commencing with Section 7000)of <br /> Division 3 of the Business and Professions Code and my license is in full force and effect. <br /> License#:.* 1 /(u 6 S68' <br /> Date: /2q/ Exp Date: slit 6,0 11 <br /> , <br /> Contractor: G-00 i� ,.{keN �CoI <br /> Signature:�H f)`�_� <br /> Title: SLcvc�aA j <br /> Print Name: <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 <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: S" '}t► K I G <br /> Policy Number: 6O-- <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 taw of California, and <br /> Labor Code, I shall forthwith comply with those provisions. <br /> agree that if I should become subject to workers'compensation provisions of Section 3700 of the <br /> Exp. Date: <br /> Signature: 7 L1 tA„ <br /> I <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 /> AUTHORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> he // (signature of C-57 licensed authorized representative), <br /> rebylauthorize(print name) _LW n ' �,pw if <br /> sign this San Joaquin county Weil Permit Application on my,behalf. nderstand this authorization is valid <br /> to <br /> for one year and is limited to the work plan dated on the front page of this application. <br /> 812W02ft <br /> EHE2"1 1115.107 <br /> WELL PERWT APP <br />