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f San Joaquin County Environmental Health DeoartmentUnEt IV Well Permit Application Supplement <br /> JOS ADdRESS- G� <br /> PERMIT 'SR#. <br /> LICENSED CONTRACTORS DECLARATION (LCD <br /> I hereby affirm that I am licensed under the provisions of Chapter 9(cornmencing with Section 7000)of Division <br /> 3 of the SUSInese and Professions Cede and my INMnse is in full force and effect. <br /> License#: C 5 - ! )-7 '5 1 F—VirWon Date_ <br /> Bate: Gant ,✓ G ! r KC, <br /> "mature: -`�- Titin: ly- M a K <br /> Printed name: 1rY1 ' l -t"c �Y e <br /> WORKERS'COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury on@ of#itis fallowingdeclarations: (CHECK ONE) <br /> _I ha4 s and will maintain a certificate of consent to self-insure for workers'compensation,as provided far ' <br /> by Section 3700 of the Labor Code,for the performance of the work for which this perrnit is issued. <br /> _I have and will maintain workers'eompensation Insurance,as required by Section 3700 of the Labor Cade, <br /> far the performance of the work for which this permit is issued.:Uy workers'Compensation inwranc:e <br /> carrier and policy numbers are: <br /> + l I <br /> Carrier: �r," Policy Number. 0 <br /> 1 certify that in the performance of the work for which this perp-d is issued,I shall not employ any person in <br /> any manner sD as to become subject to ft workers'eompan t en laws of Califomis,and agree that if I <br /> should bawd#subject to the workeW Compensation provisions of Sectlon 37 of the Lataor Code,I shall <br /> forthwith comply with those p-rolvisions.- <br /> EXpiration Date: E5 ^ISignature: . <br /> Printed Naine: <br /> WARNING:FAILURE TO SECURE WORKERS'COMPENSATIOK COVERAGE IS UNLAWFUL,AND SHALL 9UI3JECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CML FINIS UP t0 ONE HUNDRED THOUSAND DOLLARS <br /> ($100,000.),IN ADDITION TO THE COST OF COMPENSATION,INTEREST,ATTORNEY`S FEES,AND DAMAGES AS <br /> PROVIDED FOR IN SECTION 3708 OF THE L,A SOR CODE. <br /> AUTHORIZATION HER THAN C-57 SIGNING PERMIT APPLICATION , <br /> f�(c�dgnature aM-57 Ilrensed auth0dwd raprmnlatlw). <br /> 1607 <br /> hembY authodze(Print name) <br /> _ W1 ! U / ; <br /> to sign this San Joaquin County Wets Permit AppliCatlori on my behalf. I understand this authvrizaHon is valid for w <br /> ons 11)year and is limited to ttra work plan dated on tho front page of this application. <br /> 8-29-02 1 IIAI <br /> END 29.02-001 <br /> I <br /> Iy <br /> I <br />