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San Joaquin County Environmental Health Services, Unit IV Well Permit Application Supplement <br /> JOB 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 and effect <br /> License# C S7 1 7 S ( Q Expiration Date 3 <br /> Date .-Contractor 0 r=_c,C <br /> Signature Title <br /> Printed name 1I-` C- <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury 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 /> -1 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 laS 4�G Iv �f U''Z�� 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 /> Date Jr r� a Signature <br /> Printed Name 'N <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 A5 <br /> PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE <br /> 1, \/[ rOL- C 1r-1 c4 0 M G Y-\ (C-57 licensed authorized representative),hereby <br /> authorize 1 H <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 />