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San Joaquin County Envirc tal Health Department Unit IV Well 't Application Supplemental <br /> S'roc6;rD- <br /> JOB ADDRESS: 2-49V L h 6L��t r PERMIT SR # <br /> anZ 3 arl 3 e;rtr 5r-o"-n2 -q 1--91,-r- 1. <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 #: �� �L rj Exp Date: 131- 0 I d <br /> Date: 4 26- 2010 Contractor: S 50kA <br /> Signature: ` Title: V')ex <br /> Print Name: aDpviC� <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 /> LI/I 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 <br /> __ insurance carrier and policy numbers are: <br /> :JT�,71' <br /> Carriere CLM Policy Number: 0002S- 09 <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 pr visions. <br /> Exp. Date: r}- I - 20 10 Signature: /S <br /> Print Name: <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 /> ,AUTF�QRIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> I, J�.� /� (signaturett Q P- <br /> of C-57 licensed authorized representative), <br /> hereby authorize (print name) Z1�1 fF. C06 kfo i7-Y Nr& 'A,c4 -tLh . 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 /> 81291021MI <br /> EHD2}01 1115107 <br /> WELL PERMIT AF <br />