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Fi <br /> 'fan,Joaquin County =nvironmental Health Department Unit IV Well Permit Appilcation SupplemeOB ADDRESS: PERMIT SR#: <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> I he eby affirm that I am Ii mrued under the provisions of Chapter 9(commencing with Section 7000)of Division i <br /> 3 of the Business and Professions Code and my license is in full force and affect <br /> License#: A OSLO'4 C j expiration Date: l C( 3 ✓ I T L <br /> J <br /> � Dab).—N��--U'J1 Contractor: I- <br /> i <br /> Sigirature: �— j U42A9Q -� <br /> Prlrted name: <br /> WORKERS'COMPENSATION DECLARATION <br /> I hei eby affirm under pens Ity of perjury one of the following decieraWns: (CHECK ONE) <br /> I have and will mainta n a certificate of consent to self-insure for workers'compensation,as provided for <br /> by Section 3700 of the. Labor Code,for the performance of the work for which this permit is issued. <br /> I nave and will mainta n workers'compensation msurancs,as required by Section 3700 of the Labor Code, <br /> `or the performance ci the wcrk for which this permit is issued. My workers'compensation insurance <br /> :arrier and policy numbers are. <br /> t � /I <br /> Carrier: �J� I i 5 Policy Number. �N �C( L� L /- <br /> certify that in the performance of the work far which this permit is issued. I shall not employ any person in . <br /> arty 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 Sec�ion 3700 of bor Code, i shall <br /> orthwith comply with tnose provisions. <br /> I Date:_ � �c�i ( Signature: <br /> i Printed Name: <br /> WAR VtNG:FAILURE TO SE,:URE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALT_SUBJECT <br /> AN E WPLOYER TO CRIMIW,L PENALTIES AND CIVIL FINE$UP TO ONE HUNDRED THOUSAND DOLLARS <br /> i (5100,080.),IN ADDITION TC THE COST OF COMPENSATION,INTEREST,ATTORNEY'S FEES,AND 13APAAGES AS <br /> PRO\'TOED FOR IN SECTION 370$OF THE LABOR CODE, <br /> THORIZATION FOR I THER THAN C-57 SIGNING PERMIT APPLICATION <br /> I'-- (signature oft:-37 licensed authorized representative), <br /> herab y authorize tprtnt ame) :C `,GLS L t i G <br /> to sag i this San Joaquin Cohn Well Psrmit A I <br /> tY ppliratton on my behalf. I understand this authorization is valid for <br /> 1 one N I year and Is limited w the work plan dated on the front page of this application, <br /> 8-29-02/Ml i <br />