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San Joaquin County Erivlronrnental Health Services, Unit IV Well Permit Application Supplement <br /> JOB ADDRESS:_C1©J- L.P. r,pe4�,V�. _ _ PERMIT SR#: �d 2`565 iY <br /> if <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> I hereby affirm that t 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#: �lgkz Expiration Date i <br /> Date. ! -� 7 Contractor. i V a Ir i 6 { <br /> Signature; Tlki®: re sVr r <br /> Printed name: Rabe Nmerer <br /> , <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 sy t <br /> Sect,on 37CO of the Labor Cade, for the performance of the work for which thio permit is issued. <br /> 1 have and will maintain workers' compensation insurance, as required by Section 3700 of the Lebo,Code, <br /> I for the performance of the work for which this permit is issued. My workers' compensation insurance <br /> carrier and policy numbers are cq� <br /> Carrier; 6rot& 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:��—���� _Signature: <br /> { r i <br /> � Printed Name; <br /> WARNING:FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT 'I <br /> AN EMPLOYERTO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> 1[00,.),IN N ADDITION <br /> TO THE COST <br /> N 37 B OF T OF COMPENSATION,INTREST,ATTORNEY'S FEES,AND DAMAGES As <br /> P <br /> I <br /> (C-57 licensed authorized representative),hereby <br /> /1/ I <br /> /r authorize <br /> to sign this San Joaquin County Wall Permit Applleatlon on my behalf. I understand this author'zatlon Is valid for <br /> one(i)yyear and is limited to the work pian dated on the front page of this applleation_ _ <br /> b0 39V6 CrJ�� Hy�I EEt�£S9trE67 LE:9L 000'/ET/L0 <br />