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• <br /> San Joaquin County Environmental Health Services, unit IV Well Permit Application Supplement <br /> F <br /> OB ADDRESS: 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 and Professions Code and my license is in full force andeffect <br /> License # C ar_'­7 7 L-7 Sl!G Expiration Date _ I -� I —o 2l,- _ - 1 <br /> Date �3 — o I Contractor C C r � <br /> Signature Title D EC 4 fli-\ S C-i r-,,Ci <br /> Printed name V P CCS CL Y-\ <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm under penalty of penury one of the following declarations (CHECK ALL THAT APPLY) <br /> _I have and will maintain a certificate of consent to self-insure for workers compensation as provided for by <br /> • 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 I cc S K c,, NJA4 i c,-Ncz I -TnS Cio Policy Number I W S 3 O I <br /> 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 /> Date: 5 �O�Signature <br /> Printed Name ti�� r� C��l rv,) a. 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 /> ($100,000 ), IN ADDITION TO THE COST OF COMPENSATION, INTEREST,ATTORNEY'S FEES,AND DAMAGES AS <br /> PROVIDED FOR 1N SECTION 3706 OF THE LABOR CODE - <br /> Cil CL V-N/-\ Y""\ (C-57 licensed authorized representative), hereby <br /> authorize a\J + cA `2--0 <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 />