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San Joaquin County Enviror" ntal Health Department Unit IV Well F tit Application Supplemental <br /> JOB ADDRESS: Z5 0 /v,^yy Dr,�✓2 ra� PERMIT SR # <br /> I Z 1.,,c4r%an y <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 Exp Date: <br /> Date: '-} -Zo- 20 JO Contractor: F150kr ��— <br /> Signature / �- Title: OLIJ E iK <br /> Print Name: Dp'V�a t ,7!) 1-A- <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 /> V/1 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:�e Policy Number: 00 b -S— Oq <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 California, and <br /> agree that if I should become subject to workers' compensation provisions of Section 3700 of the <br /> Labor <br /> Code, I shall forthwith comply with those provisions. <br /> Exp. Date: t�- I - ZO 1 O Signature <br /> Print Name: c...90 b 1—VS IL14 <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 /> �AUT0 RIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> I, _! '.� Ate, /� (signature of C-57 �liicensed authorized representative), <br /> hereby authorize (print name) �i�� - C06 Roo a-�- Con809, (—p;C4 l e c - , 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 /> 81291021M1 <br /> EHD 2901 1115/01 WELL PERMIT AT <br />