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r-LB 17 2004 2 54PM HP LASERJET 3200 P.,P" E <br /> 021171•'04 TUB 13:39 FAX 91B 87 90 URS; <br /> Al <br /> San Joaquin County Environmental Health Department nit 1V Well Permit Application Supplement <br /> JOB ADDRESS: Z �� �� ERIYIIT SRX: <br /> LICENSED CONTRACTORS ECLARATION {LCD) <br /> I hereby affirm that I am licensed under the provisions of Cha ter 9 (cornmencing with Section 7000)of Division <br /> 3 of the Business and Professions Code and my license is in II force and effect. <br /> Ucensea:C_C7 V45Y Expiratio Date: <br /> Date: O Contractor: iae " .A <br /> Signature: I Title: <br /> Printed name: <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the following d e�clarelions! (CHECK ONE) <br /> yI nave and will maintain a certificate of consent to self-in I ure 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 /> X11 have and will maintain workers'compensation insuranc�,as required by Section 3700 of the Labor Code, <br /> for the performance of the work for which this permit is i ued. My workers'compensation insurance <br /> carrier and policy numbers are: <br /> Carrier: lit �,i.r' Policy Number:�-� (��� / Q'D Z/ 7 <br /> I certify that in the pertortnance 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'com minsallon laws of California,and agree that if l <br /> should become subject to the workers'compensation pro i1slonS of Section 3700 of the Labor Cade; I shall <br /> forthwith comply with those provisions. <br /> Date: a!!G 't— Signature: <br /> Printed Narnv: <br /> WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AMO 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 /> AVTHOFSIZATION FOR OTHER THAN C-5 SIGNING PERMrr APPLICATION <br /> 1, (a I gnature ofC-67 licensed authorised representative4 <br /> hereby authorize(print name P)i4Bn <br /> to sign this San Joaquin County Well Permit Application an my behalf, 1 understand this authorization Is valid for <br /> one(1)year and Is limited to the work plan datep on the front pi go of this application. <br /> 6-29-021 AAI <br /> i <br />