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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 /> 1 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 9 � S I U Expiration Date =_ 3 _Q <br /> Date S p Contractor C Ct C <br /> Signature Title Doe rGiT`r MCA �lr <br /> Printed name V e co, c__VN <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 wit[ 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 /> Y7 <br /> Carrier C.S K.C� AJ C4,o e,13nS Policy Numbery f E W 's <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 <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 Signature <br /> Printed Name �`c,� �- 2✓Y\ CA <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 /> 1, V'e-r 01— c_ -�� G` P.IrYN G Y-\ (C-57 licensed authorized representative), hereby <br /> authorize C %J N d q e r Z_G <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 />