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San Joaquin County Environmental Health Department Unit IV Well Permit Application Supplement <br /> JOB ADDRESS: W�'T CJI�T&Z cyryoF"jro�ERMIT SR#: 5979A <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 andProfessions Code and my license is In full force andel effect <br /> " <br /> License It !l:5/ 1 Q1 <br /> Expiration Date: V 5' 31 I I I <br /> Date:–(- � - B 1C, Contractor—AJ( i2on" <br /> Signature: G.t�_ .Tittlle: ��h"I I �Q f y� <br /> ► tanar.'e 2. <br /> Printed name: t t <br /> WORKERS' COMPENSATION DECLARATION <br /> I he7bbY affirm under penalty of perjury one of the following declarations: (CHECK ONE) <br /> +� 1 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 /> _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 /> carder and policy numbers <br /> tt[SSS <br /> are: ^� <br /> Carrier: R Policy Number: <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'compensation provisions of Section 3700 of the Labor Code,I Shall <br /> forthwith comply with those provisions. <br /> Expiration Date:�Signature: <br /> Printed Name: aA-t) <br /> 11 <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 /> AUT jH/Q YZAON FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> Ti (signature ofC.57 licensed authorized representa0vei, <br /> hereby authorize(print name) ic� Git/1bJz --Apr t F1NtYu[Ytr–f y, iAk, <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 /> 8-29-02 f MI <br /> EHD 2M2-001 <br /> 9noro02 <br />