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• wr V <br /> San Joaquin County Environmental Health Department Unit IV Weil Permit Application Supplement <br /> JOB ADDRESS: Z 56O /1VV Y Dal 26- PERMIT SR#: ,`J9 X87 <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}Proofessiioons Code and my license is in full force and effect. <br /> t0 <br /> License#: 59 aD Expiration Date: OS' 31 <br /> Date:_("DIS ' - 10 Contractor: IV V) <br /> Signature: Title: -)CACn <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 /> _I have and will maintain workers'compensation insurance,as required by Section 37DO of the tabor Code, <br /> for the performance of the work for which this permit is issued. My workers'compensation insurance <br /> carrier and policy numbers <br /> 'are: ^� <br /> Carrier:-RES L Policy Number. N+�� <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:—L)A– . –Signature: <br /> Printed <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 3709 OF THE LABOR CODE. <br /> ALIMRIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> (signature ofC57 licensed authorized representative), <br /> hereby authorize(print name) <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 application. <br /> 8.29-02/MI <br /> ERD 29M.D01 <br /> 9130/2002 <br />