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San Joaquin County Environmental Health Department Unit IV Well Permit Application Supplement <br /> JOB ADDRESS: /�0( RaYIIA L�: PERMIT SR#: <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> I hereby affirm that I 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 0: C 5� - 1-15 ) U Expiration Date:: I 1 v J 1 D 0 <br /> Date: &— 1 - 0 (0 Cont c r:-C, 0 S C-6XA ef, <br /> n -P � I � I {�� , � )A& <br /> Signature: G� ` ,— y Tltlea > 4 e-,y- Ops M.ax J <br /> Printed name: e,Y-n e S �V ` ( -el V-y-e IF- <br /> WORKERS'COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one or 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 /> _I have and will maintain workem'compensation Insurance, as required by Secdon 3700 of the Labor Code, <br /> for the performance of the work for which this permit is issued. My workers'compensation insurance <br /> canierand policy number's are: <br /> Carrier: &' PLI,-V-A "N a- ` � OK A�1( Policy Number: <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 se 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 37 of the Labor Code, I shall <br /> forthwith comply with those provlslons. <br /> Expiration Date: 5 - _ (:) 7Signature: <br /> QAC <br /> Printed Name: <br /> WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CML FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> (;f DO,oOo.j,IN ADDITION TO THE COST OF COMPENSATION,INTEREST,ATTORNEY'S FEES,AND DAMAGES AS <br /> PROVIDED FOR IN SECTION 3106 OF THE LABOR CODE. <br /> AUTHORIZATION �O CHER THAN C-57 SIGNING PERMIT APPLICATION <br /> I, r`gnatura ofC-57 licensed authorized representative), <br /> hereby authorize(print name) t cif, L I &-- <br /> to sign this Sari Joaquin County Well Permit Application on my behalf. 1 understand this authorization is valid for <br /> one i1)year and is limited to tho work plan dstad on the front page of this application. <br /> 8.29-021 MI <br /> Ei 2902-001 <br /> /✓'�2ma <br />