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San Joaquin County Environmental Health Department Unit IV Well Permit Application Supplement <br /> JOB ADDRESS: sol East charter way PERMIT SR*: <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 aand/Pr�offessions Code and my license is in full force and effect. <br /> License#: *w6- <br /> Expiration Date: 110 <br /> Date: wI ' C1 99&ontract -Ni 4lI x,� I'd1� <br /> Signature: ,�,1�l� Title:WOLAbcks Ipl *- <br /> 4r <br /> Printed name:air15��`�, Au - <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 /> 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 <br /> (policy <br /> lnumbers are: a2 <br /> Carrier: 1, (�lClJl> Policy Number: r7ll��D��pl <br /> I certify that in the performance of the work for which this permit is issued, 1 shall not employ any person in <br /> j 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 provis' ns of Section,37P of the Labor Code, I shall <br /> forthwith complyq with those provisions, <br /> Expiration Date: Signature: <br /> Printed Name: v►,IZI /WI' 'r ' `-" � <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 /> HER THAN C-57 SIGNING PERMIT APPLICATION <br /> (slgnature ofC-57 licensed authorized representative), <br /> hereby authorize(print name) Ally colavita <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 /> B-29-02/MI <br /> EHD 29-02.001 <br /> 6/22/04 <br />