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San Joaquin County Environmental Health Department Unit IV Well Permit Application Supplemental <br /> JOB ADDRESS: <br /> 3WZ M <br /> Ch V�S "W-PERMIT SR# <br /> Ir <br /> T 1,-I0,cul 015 6—, (0 <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> I hereby affirm that I am licensed under the provisions of Chapter 9(commencing with Section 7000)or <br /> Division 3 of the Business and Professions Code and my license is in full ford and effect. <br /> License#: 0-16 Iv Exp Date: <br /> Date: <br /> A Contractor: <br /> Signature: Title: <br /> Print Name: V-� <br /> WORKER'S COMPENSATION DECLARATION <br /> iv C'! <br /> J <br /> J J <br /> eI-,-I i t i ISS u e, <br /> and vvorl,,ers connpe-isaulon lrisurance ,as required by S( i o;i 3 7-0 o, <br /> abot Code,for the pe' orrnance wl i;)e workf'-r which this pen-nit is Issued. Miy%uork&S' <br /> compensation insurance carnei and policy numbers are: <br /> Carrier: Policy Number: <br /> I certify that in the performance of the work for which this permit is issued, I shall not employ any <br /> person in any manner so as to become subject to the workers'compensation law of California,and <br /> agree that if I should become subject to workers'compensation provisions of Section 3700 of the <br /> Labor Code, I shall forthwith comply with those provisions. <br /> Exp.Date: Signature: <br /> Print Name: <br /> WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT AN EMPLOYER TO <br /> CRIMINAL PENALTIES AND CIVIL FINES UP TO$100,000,IN ADDITION TO THE COST OF COMPENSATION,INTEREST, <br /> ATTORNEY'S FEES,AND DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. <br /> AUTHORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> (signature of C-57 licensed authorized representative), <br /> hereby authorize(print name) I,_ ,to <br /> sign this San Joaquin county Well Permit Application on my behalf. I understand this authorization is valid <br /> for one year and is limited to the work plan dated on the front page of this application. <br /> 81291021MI <br /> EHD29-01 1115/07 WELL PERMIT APP <br />