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San Joaquin County Environmental Health Department Unit IV Well Permit Application Supplement <br />JOB ADDRESS: PERMIT 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 Division <br />3 of the Business and Professions Code and my license is in full force and effect. <br />License #: 5 13 Expiration D e: j <br />Date: I - I 4 - 0 5 Contractor: CaSCCAS NOil-NIG‘ n <br />Signature: Title: c)1kç j t%0Ai, rn3r, <br />WORKERS' 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 provided for <br />by Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. <br />X_ I have and will maintain workers' 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 /> <br />Carrier: N65-)\<ok. Ntakoroti Policy Number <br />I certify that in the performance of the work for which this permit is issued, 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 ojSectn 3700 of the Labor Code, I shall <br />forthwith comply with those provisions. <br />Expiration Date: E5H I 0 (.0 Signature: <br />Printed Name: s—rifl, C4 6\9 <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 HUNDRED THOUSAND DOLLARS <br />0100,0004, IN ADDMON TO THE COST OF COMPENSATION, INTEREST, ATTORNEY'S FEES, AND DAMAGES AS <br />PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. <br />AUTHORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> <br />74'414-11 6.-- <br /> <br />(signature ofC-57 licensed authorized representative), <br /> <br />hereby authorize (print name) <br /> <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 />8-29-02 / Mi <br />Printed name: "TAlc\-1-0\v, r <br />EHD 29-02-001 <br />6/22/04