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v <br /> LI \ 11,1111 C. b" �/ <br /> San Joaquin County Environmental Health Department Unit IV Well Permit Application Supplemental <br /> G <br /> JOB ADDRESS: 4- Q,t va P f#yt _' d C4 PERMIT SR # Z 3 S g —CO <br /> I l� .2acut-w lam; ply <br /> 2- <br /> LICENSED <br /> LICENSED CONTRACTORS DECLARATION (LCD) �f �� <br /> 1 <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 #: G� �����(� Exp Date: <br /> I Date: /f Contractor: <br /> Signature: Title: <br /> I <br /> Print Name: <br /> i <br /> WORKER'S COMPENSATION DECLARATION . <br /> I hereby affirm under penalty of perjury one of the following declarations: (check one) <br /> i <br /> I have and will maintain a certificate of consent to self-insure for workers'compensation, as <br /> I 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: r <br /> 5 �` ?� Policy Number: !��/r� �� 2Y <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 provision . <br /> Exp. Date: Signature: <br /> Signature: <br /> Print Name: <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 /> (A0 Z N FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> I, (signatur of C-57 licensed authorized representative), <br /> hereby authorize(print name) ��(� ; 1 e r ,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 workplan dated on the front page of this application. <br /> 8129102/MI <br /> EHO 29-01 1115107 WELL PERMIT APP <br />