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Il4ar 11 08 10:02a GE&R 2( 13-3990 p.3 San Joaquin County Environmental Health Department Unit IV Well Permit Application Supplement JOB ADDRESS: PERMIT SR#: LICENSED CONTRACTORS DECLARATION (LCDr I hereby affirm that I am licensed under the provisions of Chapter G(commencing with Section 7000)of Division 3 of the Business and Professions Code and my licerse is in full force and effect. License#: Expiration Date: Date:_ �'��'� Contractor: ` lela i �'N Signature: 2�� .G� o Title: Printed name: %77ke y j f fy�{O WORKERS' COMPENSATION DECLARATION I hereby affirm under penalty of perjury one of the following declarations: +CHECK ONE) I have and will maintain a certificate of consent to self-insure for workers' compensation, as provided for by Section 3700 of the Labor Code, for elle performance of the work for which this permit is issued. I have and will maintain workers'compe.-isation insurance,as required by Section 3700 of the Labor Code, for the perfDrmance of the work for which this permit is issued. hly workers' compensation insurance carrier and policy nu Carrier: Z L)Ir L C r l AMer, cay, Policy Number: I cenity tha-in the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to become subject to the workers'compensation laws of California, and agree that if should become subject to theworkers'compensation provisions of Section 3700 oflhe Labor Code, I shall forthvnth comply with those provisions. L Expiration Date: Y-1-4SSignature: Printed Name: WARNING: FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS ($11100,000.),IN ADDITION TO THE COST OF COMPENSATION,INTEREST,ATTORNEY'S FEES.AND DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. AUTHORI7-0.TION FOR OT N THAN C-57 SIGNING PERMIT APPLICATION! 1, (signature oIC-57 licensed authorized representative), hereby authorize(print name) 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 thework plan dated on the front page of this application. 8-29-021 MI iJ ID 219.02•au 62'_414 £'d LbLS-8£9-9L6 dJoD 6ullpC] eouau V1sa I ef'f::L L 90 LL Jew