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0 <br /> (7 <br /> San <br /> San Joaquin County EnvironmentalDepartment Unit IV Well Permit Application Supplement <br /> JOB ADDRESS: 5/ l Stn PERMIT SR#: D 5Ys93 <br /> LICENSED CONTRACTORS DECLARATIONL( CD) <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 Professions Code and my license is in full force and effect. <br /> License#: Expiration Date: <br /> Date: Contractor. <br /> Signature: Title: <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 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 are: <br /> Carrier: 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: <br /> WARNING:FAILURE TO SECURE WORKERS' ATOM COVERAGE IS UNLAWFUL,AND SHALL SUBJECT <br /> AN lMPLOYEIt TO CWMNAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> (t100,g60.),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 /> AUTHORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> (skinature ofCd7 licensed authorized representative), <br /> hereby authorize(print name) Brad Shelton J <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 M limited to the work plan dated on the front page of this application. <br /> 6-2&021 MI <br /> EHD 29-02-001 <br /> 622/00 <br />