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'Au; ?2, 2009 3:59PM A ( 5 L1 x:. 03 <br /> 1 <br /> San Joaquin County Environmental Health Department Unit IV Well Permit Application Supplemental f <br /> JOB ADDRESS: 5t, ERMIT SR# 6 5871 b <br /> f <br /> f <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> I hereby affirm that I am licensed under the provisions of Chapter 9(commencing with Section 7000)of <br /> Division 3 of the Business and Professions Code and my license is in full force and effect. <br /> license#: _q D a►'_'M Exp Date: 7,0 l 1) <br /> Date: A Lt.0 u st 1`1 D LSI Contractor: <br /> I <br /> Signature: Title: C P r M 19100,�-fy <br /> Print Name: 0EV Y�1 <br /> WORKER'S COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the following declarations: (check ane) <br /> I have and will maintain a certificate of Consent to self-insure for workers'compensation, as <br /> provided for by section 3700 of the labor Code, for the performance of the work for which this <br /> permit Is issued. <br /> I have and will maintain workers'compensation insurance, as required by Section 3700 of the <br /> Labor Code, for the performance of the work for which this permit is issued. My workers' <br /> compensation insurance carrier and policy numbers are:: n <br /> Carrier: 6Policy Number: �c1 A!p <br /> I certify that in the performance of the work for which this permit is issued., I shall not employ any <br /> person in any manner so as to become subject to the workers'compensation law of California, and <br /> agree that if I should became subject to workers'compensation provisions of Section 3700 of the <br /> Labor Code, I shall forthwith comply with those provisions. <br /> Exp.Date: 1 Z Zo 2010 Signature: <br /> Print Name; L6D'n <br /> WARNING-.FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE 15 UNLAWFUL,AND SHALL SUBJECT AN EMPLOYER TO <br /> CRIMINAL PENALTIES AND CIVIL FINES UP TO$100,000,IN ADDITION TO*HIE COST OF COMPENSATION,INTEREST; <br /> ATTORNEY'S FEES,AND DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. <br /> WHO IZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> i, (signature of C-57 licensed authorized representative), <br /> here orize(print name) 1 F L 1 SSA S'i R-$4T h N ,to <br /> sign this Senn Joaquin county Well Permit Application on my behalf. I understand this authorization is valid <br /> for one year and Is limited to the workplan dated on the front page of this application. <br /> a149iDlJ11tI <br /> GWD2 or 11W WEL6pERurrAPP <br /> i <br />