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.�, i . �i�u�o�oil l,fi�lHUtllK1LL1Nla PAGE 02/04 <br /> FSa, Joaquin County Environmental Health Department Unit,IV 1)Uell Permit Application Supplement <br /> ADDRESS: ?— L� OY(AAO PEIRMIIT SR*,, <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> i hereby affirm that I am licensed under the provisions of Chapter 9(corhmencing with Section 7000) of Division <br /> 3 of the Business and'Professions Code and my license is in full force and effect. <br /> License#: t>-7 1-7 51 Q oiration Date: <br /> Date: � C_I � �p� Contrac r: �t��2.G <br /> Signature: Title: --� <br /> Printed name: j 7/L�`���•Z <br /> WORKERS' COMPENSATION DECLARATiON <br /> I hereby affirm under penalty of perjury one of the follow)ng diaclarations: (CHECK ONE) <br /> _I have and will maintain a cer1lilcate of consent to selMnsure for wdrkers'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 /> 1 have and will maintain workers'compensation In as requ"d 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: <br /> �� ( NP�-"jCJYtGt-{- policy Number;�(o (.US� u� I _ <br /> I certify that in the performance of the work for which this permit is)SaUed, 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 provisions of Sectio 3704 of the l ehor Code, I shall <br /> forthwith comply with those provisions, <br /> Expirgtion Dater 07Signature: <br /> Printed Name: <br /> WARNING:FAILURE TO SECURE WORKERS'COMPENSATiON COVERA05IS UNLAWFUL,AND'SHALL SUBJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CIViL FINES UP TO ONE HUNDRED THOUSAND 601-1-ARS <br /> ($100,000.),iN ADDITION TO THE COST OF COMPENSATION,INTEREST,A fTORNF_rS FEES,ANb DAMAGES As <br /> PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. <br /> A!!TH RiZATION O o t/,E/r THAN C-57 SIGNING PERMIT APPLICATION <br /> i' (signature ofC-97 licensed authorized representative), <br /> hereby authorize(print name) <br /> to sign this San Joaquin County Well Permit Application on my behalf. I ungtratand this authorization is valid for <br /> one(1)•yoar and is limited to the work plan dated on the front page of this application. <br /> 8.29-02(Mt <br /> EliD 24.O1.ggl ' <br /> 6r�b'n4 <br />