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county Environments!Health i3epartment Unit 4V Weil perNOV <br /> mit Application Supplement <br /> San Joaquin C ty PERMIT SR#: <br /> JOB ADDRESS: 7 <br /> LICENSED CpNTRAGTORS DECLARATION (LCDmrnencin ) <br /> with Section 7000)of Division <br /> I hereby affirm that I d Professions Code androvisions of my license s inn fullforceforce and effectt.. <br /> 3 of the Business an A17U 2OD5 <br /> License#: <br /> &Y ZZ? Expiration Date: <br /> : <br /> 7 f&f - Contractor: <br /> Date-.7/&/6- <br /> ate <br /> Title: <br /> Signature: / <br /> (�J �v I <br /> Printed name: <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the following declarations: (CHECK ONE) <br /> 1 eand will maintain a ction 3700 of the LabortCode, for the performanificate of consent to fce of the wok for which this-insure for workers' nperm t is issueded for <br /> byy Section <br /> I 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: 2 <br /> Carrier: Policy Number: <br /> l 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 l <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: Signature: <br /> Printed Name: <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 /> ($100,000.), 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 /> I, (signature ofC-57 licensed authorized representative), <br /> hereby authorize(print name) <br /> to sign 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 application. <br /> 8-29-02 1 MI <br /> EHD 29-02-001 <br /> 6/22/04 <br />