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Maw 15 fit &5:0 Bs, Wes ��2 P. i, <br /> ;0,,Joaquir County Environmental Health Services,Unit IVWell Permit Application Supp l�e t <br /> JOB ADDRESS. `1026 )\,P�t ) ttlti YX'f .)PERMIT SR#: 512 � (�( <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> I herebv affirm that I am licensed under the provisions of Chapter 9(commencing with Section 7000)of nivictnn <br /> 3 of the Business and Professions Code and my license is in full force and effect. <br /> 0 7Q// i f <br /> License#: lU tl,'7[ll( 7 Expiration Date: l ,3) -U C <br /> Date: r^ (1 Can'vactor. •i \fX.IV <br /> Signature: _/14 Title: 66J LL/1 <br /> Printed name: cfJQt/L(Y �c�Cl� <br /> WORKERS' COMPENSATION DECLARATION <br /> 1 hereby affirm under penalty of perjury one of the following declarations: (CHECK ALL THAT APPLY) <br /> _I have and will maintain a certificate of consent to self-insure for workers' compensation, as provided for by <br /> 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 policy numbers are: <br /> Carrier:�S ( '� en cn Policy Number: 153626S -00 <br /> Q <br /> _ I certify that in the performance of the work for which this permit is issued, t shall not employ any person in <br /> any manner so as to become subject to the workers' compensation taws of California, and agree that if 1 <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 /> Date:s� C�-`� ( Signature: _/�f{ <br /> Printed Name: J XJ i/ ( 1 <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 THELABOR CODE. <br /> I, N V) SCA4 (C-57 licensed authorized representative),hereby <br /> authori <br /> to sign this San Joaquin County Well Permit Application on my behalf. 1 understand this authorization is valid for <br /> one(1)year and is limited to the work plan dated on the front page of this appl'scation. <br /> 5.17-2000/MI <br />