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r <br /> ,v6 � #4 <br /> lZ � Z9. 4 d <br /> San Joaquin Countyy Environmental Health Department Unit IV Well Permit ApCpliicc tion Supplemental <br /> �! ?+ <br /> JOB ADDRESS: / /"VG'�GA* RMIT SR# ` <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> I hereby affirm that I am licensed under the provisions of Chapter 9 (commencing with Section 7000)of <br /> Division 3 of the Businessand Professions Code and my license is in full force and ffect. <br /> License#: 737073 Exp Date: 3 J 2 <br /> Date: Contractor: RMA �_�isz,W to rvAe"J L�1 S. <br /> Signature: I Title: {�w ^- <br /> Print Name: I.Jt/wlT ^ /J1. <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 /> X_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: )f wd Policy Number: 16' S6 4 ( l _o l <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 pr Bions of S on 3700 of the <br /> Labor Code, 1s all orthwith comply with those provi ' s\ <br /> Exp. Date: v Signature: <br /> Print Name: C 1^,✓ X tntifc.�j <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 /> �A 1 N FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> I, (signature of C-57 licensed authorized representative), <br /> hereby authorize(print name) O\ ✓ p 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 /> 9129/021MI <br /> EHD 2401 111W <br /> WFUL PERMIT APP <br />