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San Joaquin Co Env ronmental Health Department Unit IV Well Permit Application Supplement <br /> 1U9 1� � 1 S?-v E, Sa,,}ds Apt. <br /> JOB ADDRESS. �22 r1i S, MLAr oZ PERMIT 5R#: <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> hereby affirm that 1 am licensed under the provisions of Chapter 8(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*: 60" 5514 _Expiration Date:. 1'QJ <br /> Date: l ` O� Contractor:�eSO h(;�YL+' SO v�(c L3'yH • L.1 LC . <br /> Signature' Title- tl7 Sc'=ec<•t <br /> Printed name: <br /> WORKERS'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 provided for <br /> by Section 3700 of the Labor Code,for the performance of the work for which this permit is issued. <br /> have and will maintain workers'compensation insurance,as required by Section 3700 of the Labor Code. <br /> for the performance of the work for which this permit is issued. My workers'compensation insurance <br /> carrier and policy numbers are: n �,L <br /> carrier: AVVYlc V6 V1�d t1��(�IC�eSPolicy Number:UU 1 CC,:� <br /> 1 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 /> Expiration Date:}201 "2—oSignature: \ �� <br /> Printed Name: _ j_v1�1 <br /> WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL.AND SHALL SUBJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> ($100,004.),IN ADDITION TO THE COST OF COMPENSATION,INTEREST,ATTORNEY'S FEES,AND DAMAGES AS <br /> PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, <br /> AUTHORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> (signature ofCS7 licensed authorized representative), <br /> trereby authorize(print name CKCti>r Ifo <br /> to algn this San Joaquin County Well Permit Application on my behalf. I understand this authorization Is valid for <br /> one(1)year and Is limited to the work plan dated on the front page of this appil0atlon. <br /> 6-29.021 MI <br /> EHD 29-02.001 <br /> 6/22104 <br />