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San Joaquin County environmental Health Department Unit IV Well Permit Application Supplement <br />JOB ADDRESS: a 1 15 W. Wasliy-t n S4. PERMIT SR#: 2- <br />, <br />LICENSEE, CONTRACTORS DECLARATION (LCD) <br />hereby affirm that I am licensed under the provisions of Chapter 9 (commencing with Section 7000) of Division <br />3 of the Business and Professions Code and my license is in full force and effect <br />License #.S Expiration /64 Expiration Date' c.) <br />Date; Ci -25- C'\;•• Contractor men <br />Signature-, <br /> <br />Title: Ca_fl't 6- <br /> <br />Printed name:: SCAir <br />WORKERS' COMPENSATION DECLARATION <br />hereby affirm under penalty of perjury one of the following declarations. (CHECK ONE) <br />have and will maintain a certificate of consent to self-insure for workers* 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 />nave and will maintain wonkers 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: S e <br />certify that in the performance of the work for which this permit is issued, (shall noternploy 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 Section 3700 of the Labor Code. I shah <br />forthwith comply with those provisions <br />Date: Signature: <br /> <br />Printed Name: Da Yi d • /QC/ f-C • <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 H.UNDRED THOUSAND DOLLARS <br />f$100,0Q13.), IN AUDITION TO THE COST OF COMPENSATION, INTEREST, ATTORNEY'S FEES, AND DAMAGES AS <br />PROVIDED FOR WISECTION 370S OF THE LABOR CODE. <br />AUTHORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br />41//r0 (signature ofC-57 licensed authorized representative), <br />„ <br />hereby authorize ;print name) <beL.-L-/y <br />, <br />KU, <br />to sign this San Joaquin County Well Permit Application on my behalf_ 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--2S 02 / MI <br />Policy Number: <br /> <br />3-31-1996 6 06AM FROM <br /> P. 2 <br />4V1 UEL I vi ronm.entaki No.2527 P. 2