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San Joaquin County Environmental Health Services, Unit IV Well Permit Application Supplement <br />JOB ADDRESS: 97`-- PERMIT SR#: <br />LICENSED CONTRACTORS DECLARATION (LCD) <br />I hereby affirm that lam licensed under the provisions ofCfikter 9 (commencing with Section 7000) of Division <br />3 of the Business anckProfessions Code and my license is in%ii force and effec . <br />License #: Expiratiob Date: <br />s <br />Contractor: 2.71;:PEglia.sc"- <br /> — <br />Signature: 1/e(11-) Title: <br />Printed name. <br /> <br />WORKERS' COMPENSATION DECLARATION <br />)4,ese <br />I hereby affirm under penalty of perjury one of the following declarati ns: (CHECK ALL THAT APPLY) <br />I haVe and will maintain a certificate of consent to self-insure for workers' compensation, as provided for by <br />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,::Cormiensation insurance, as required by Section 3700 of the Labor Code, <br />for the performance of the work for whicKithis permit is issued. My workers' compensation insurance <br />carrier and policy numbers are: <br />Carrier: ->,•le_ i4ei4_ 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 of Section 3700 of the Labor Code, I shall <br />forthwith comply with those provisions. <br />Date: Signature: <br />Printed Name: <br />WARNINGifAILURE 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 />($100,000.), IN ADDITION TO T,HE COST OF COMPENSATION, INTEREST, ATTORNEY'S FEES, AND DAMAGES AS <br />PROVIDED FOR IN SKI/4* 37115 OF THE LABOR CODE. <br /> <br /> (C-57 licensed authorized representative), hereby <br />;'- authorize <br />to sign 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 />5-17-2000 I MI <br />1 <br />Date: //,/,/,-/.,