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San Joaquin County Environmental Health Department Unit IV Well Permit Application Supplement <br /> JOB ADDRESS: 1 0C O e . 14w 1Z f_T 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 Division <br /> 3 of the Business and Professions Code <br /> 7and my license is in full force and effect. <br /> / <br /> License#: CL S�' `7 L) / Expiration Date: 0/37 <br /> Date:I Z- )T. /LZ, Contractor: C / `1 L <br /> Signature: ) _Z, Title: ?Q /f <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 /> 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. L,L% ! / f / .� Policy Number: <br /> 66 /266/oz& <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'comp nsation provisions of Section 3700 of the Labor Code, I shall <br /> forthwith comply with thos/e provisions. ^ l <br /> Expiration Date: —[C�, 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 /> r/ <br /> AUTHORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> I, __[•��(.f-�J�CiI ( � tl/�� I (signature ofC-57licensed authorized representative), <br /> hereby autboriz (print name) Irl 1K NAEL �- MC LEod <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 /> B-29-02/MI <br /> EUD 29-02.001 <br /> 6!22/04 <br /> 6 'd 91LS6T6S2G uapTam R..taW 991 : 11 f+0 OC o00 <br />