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JA"J�lRC.,.aP <br />06/04/2004 16:06 <br />HOP I?GN <br />916-852-9558 <br />p.3 <br />PAGE 03 <br />San County Environmental Health Dopartment Unit IV Well Permit Application S <br />upple <br />ment <br />ADDRE S:(Z PERMIT SR#: ()o31V7_7 <br />CAk/,10 <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 #: 6 7 61-7 Expiration Da.e: <br />Date: ,� Contractor. AA (i �'ff5 LC 00 t L-" f`1 C- <br />Signature: �� Title: <br />Printed name:�J <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' com pensation, 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 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 rumbers are: <br />Carrier:`2"' 7 Policy Number: 0 65 J 6�-' i <br />I certify that in the performance of the work for which this permit is issued, I shall not employ any persnr, 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: <br />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 />(5100,000.), IN ADDITION 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 />I; (signature ofC-57 licensed authorized representative), <br />hereby autharize (print name) e� 1 5� �� / [re C t C N -<% Ur - <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 />IMI <br />