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I San Joaquin County Environmental Health Services, Unit IV Well Permit Application Supplement JOB ADDRESS: PERMIT SR#: j i LICENSED CONTRACTORS DECLARATION (LCD) I hereby affirm that I arra licensed under the provisions of Chapter 9 (commencing with Section 7000)of Division 3 of the Business and Professions Code and my license is in full force and effect. License#: _ Expiration Date: Date:_ _ Contractor i { Signature: Title: i r Printed name: WORKERS' COMPENSATION DECLARATION I hereby affirm under penalty of perjury one of the following declarations: (CHECK ALL THAT APPLY) I have and will maintain a certificate of consent to self-insure for workers' compensation, as provided for by E Section 3700 of the Labor Code,for the performance of the work for which this permit is issued, I have and will maintain workers'compensation insurance, as required by Section 3700 of the Labor Code, . for the performance of the work for which this permit is issued. My workers' compensation insurance carrier and policy numbers are: Carrier: _ Policy Number: I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to became subject to the workers' compensation laws of Califomia, and agree that if I should became subject to the workers'compensation provisions of Section 3700 of the Labor Code, I shall forthwith comply with those provisions. Date: Signature: Printed Name: WARNING: FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENAL-nES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS ($100,000.),IN ADDITION TO THE COST OF COMPENSATION, INTEREST, ATTORNEY'S FEES,AND DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. 1, (C-57 licensed authorized representative),hereby authorize to sign this San Joaquin County Well Permit Application on my behalf. I understand this authorization is valid for one (1)year and is limited to the work plan dated on the front page of this application. 5-17-2000/Ml