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San Joaquin County Environmental Health Department Unit IV Well Permit Application Supplement <br /> JOB ADDRESS:256o A,/At/y/Mo � u �yPERMIT SR#: ,5` Z'9 <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 <br /> 7 Pt <br /> Professions Code and my license is in full force and effect, <br /> — <br /> License#_ ii OSq Q —1 Expiration Date: 05 , 31 - 11 <br /> Date: t V Contractor. <br /> Signature: hLuw.. <br /> K�TyitleC: Wk <br /> DCMona <br /> a (Z <br /> Printed name: b <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 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�a{'m: c � <br /> Carrier: t Jl 0s ff Policy Number- f1�, ^'1,U <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 Dater yv_0Signature: _ <br /> Printed Name: C <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 /> (5100,000.),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 /> I, L7HORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> w I1Jf'AA.Ag / (signature o(C-67 licensed authorized representative), <br /> hereby authorize(print name) / J �" OK I�:ayeoiik 254-krif "TY— _a,2:a,r A5 ,1A,�^• <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 29-01-W I <br /> 9!30(2002 <br />