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U441 ;�r, 6 <br /> San Joaquin County Environmental Health Department Unit IV ell Permit/Afpppliicc'ation Supplemental <br /> JOB ADDRESS: PERMIT SR# 1 lam(/ O <br /> __ZVLICENSED CONTRACTORS DECLARATION (LCD) <br /> 1 hereby affirm that I am licensed under the provisions of Chapter 9 (commencing with Section 7000) of <br /> Division 3 of the Business and Professions Code and my license is in full force and effect. <br /> License#-: 1D�3?IDS <br /> Exp Date: I `t3 I -�()I CQ_ <br /> -1 <br /> Date. - 0:7 - I O Contractor: <br /> Signature 2 . Title: O LsJ <br /> Print Name: l <br /> WORKER'S COMPENSATION DECLARATION <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 <br /> provided for by section 3700 of the labor Code, for the performance of the work for which this <br /> permit is issued. <br /> I have and will maintain workers' compensation insurance, as required by Section 3700 of the <br /> Labor Code, for the performance of the work for which this permit is!issued. My workers' <br /> compensation insurance carrier and policy numbers are: <br /> Carrier: C Policy Number: 10 <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, Ishall forthwith comply with those provisions. <br /> Exp. Date: -ao I I Signature: 4D�l r <br /> Print Name: bjgy? � �'L SCb4 <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 THEZT <br /> R CODE. <br /> AUT TION FOR OTHER THAN C-57 SIGNING PE <br /> A APPLICATION <br /> I ��� (signature of C-57 license authorized representative), <br /> hereby authorize(print name) ,to <br /> sign this San Joaquin county Well Permit Ap Iication 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 /> R1291021M I <br /> rjin79n1 1115MI, WELL PERMIT APV <br />