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C. <br /> San Joaquin County Environmental Health Department Unit IV Well Permit Application Supplement <br /> JOB ADDRESS: Ai-7 UoL,.e. PERMIT SR#: <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> I hereby affirm that 1 am licensed under the provisions of Chap er 9 (commencing with Section 7000)of Division <br /> 3 of the Businesr�s land/Prooffessions Code and my license is in full force and effect. <br /> 1p <br /> License#: �d. )�(�v Expiration Date: <br /> 1 <br /> Date: //—,20 -Q<- Contractor: Z))ZtW XJ6— <br /> i <br /> Signature- Title: D�IUe� <br /> Printed name: Q� �SG# <br /> WORKERS' COM PENSATIOI DECLARATION <br /> i <br /> I hereby affirm under penalty of perjury one of 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 /> Eby Section 3700 of the Labor Code, for the performance o the work for which this permit is issued. <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: <br /> Carrier: 5 aAr Compns- PLv,,A Policy P umber: <br /> certify that in the performance of the work for which this p rmit 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 I <br /> should become subject to the workers'compensation provi 3ions of Section 3700 of the Labor Code, I shall <br /> forthwith comply with those provisions. <br /> I <br /> Expiration Date: W-1-67 Signature: 1 <br /> Printed Name: V1 A-scki <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 M <br /> ($100,000.),IN ADDITION TO THE COST OF COMPENSATION,INT REST,ATTORNEY'S FEES,AND DAMAGES AS <br /> PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. <br /> AUTHORIZATION FOR OTHER THAN C-57SIGNING PERMIT APPLICATION <br /> 1, (sig ature ofC-57 licensed authorized representative), <br /> hereby authorize(print name) 1/)ieomene_e�o <br /> to sign this San Joaquin County Well Permit Application on my be half. 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 /> 8-28-021 Ml <br /> EHD 29-02-001 <br /> 6122104 <br /> C <br />