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San Joaquin County Envi cental Health Department Unit IV Well tit Application Supplemental <br /> JOB ADDRESS: LU d ' � � PERMIT SR # ®557'3 <br /> C11r5 i--}35 G <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 #: 6wA+1A C "r '4 Exp Date: (q <br /> Date: C7 Contractor: FvIC� Wyt_�U LA <br /> Signature: Title: Gt" 4M Ef- <br /> Print Name: (�� t) C)LFA Vvi <br /> WORKER'S 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 <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: �/� <br /> Carrier: /_'6��y Policy Number: W4 �r<Tl L'06e-©660( 7 <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 become subject to workers' compensation provisions of Section 3700 of the <br /> Labor Code, I shall forthwith comply with those provisions. <br /> 94 <br /> Exp. Date: 0 g Signature: <br /> Print Name: �� e�i't-vz <br /> WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT AN EMPLOYER TO <br /> CRIMINAL PENALTIES AND CIVIL FINES UP TO$100,000,IN ADDITION TO THE COST OF COMPENSATION,INTEREST, <br /> ATTORNEY'S FEES,AND DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. <br /> UTH I,nl N F --THER THAN C-57 SIGNING PERMIT APPLICATION <br /> 1, _ (signature <br /> / of C-57 licensed authorized representative), <br /> hereby authorize (print name) to <br /> sign this San Joaquin county Well Permit Application on my behalf. I understand this authorization is valid <br /> for one year and Is limited to the work plan dated on the front page of this application. <br /> Ar2QMWMI <br /> EHD 29-01 11667 WELL PERMIT APP <br />