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JAW1@4904:48p <br />08/04/2004 16:06 <br />HORIZON <br />916-852-9558 <br />p.4 <br />PAGE 04 <br />San Joaquin County Environmenrt�al Health Department Unit IV Well Permit Application Supplement <br />J B ADDRES ���� F,45+4"O-Atv PERMIT SR#: 03 2 <br />�z- <br />LICENSED CONTRACTORS DECLARATION (LCD) <br />1 hereby affirm that 1 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 #. TZ (a f 7 ^ Expiration Date: .3 ° �Z (5-7' <br />Date: Contractor. !t4* l'T1ft'rC- Pf-i.L l & <o�jP <br />Signature: ��'"`� , Title:y <br />Printed name: 6 �1 �U �y�G2� <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 />i< I have and will maintain workers' compensation insurance, as required by Section 3700 of the Labor Code, <br />for the performance of the work fq�Which this permit is issued. My workers' compensation insurance <br />carrier and policy numbers are: <br />Carrier: u9-Ltrl;A-- 5oi! ( ( <br />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 />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 />(S100,000.), IN ADDITION TO THE COST OF COMPENSATION, INTEREST, ATTORNEY'S FEES, AND DAMAGES AS <br />PROVIDEO FOR IN SECTION 3706 OF THE LABOR CODE. <br />AUTHORI?ATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br />hereby authorize (print name)_ C2�N�{��j,�><Z�iN <br />ofC-57 licensed authorized representative), <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 />