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awa <br />r - <br />San Joaquin County Environmental Health De <br />rtmont Unit IV Wall Permit Applicado S ppiement <br />JOB ADDRESS:_1 Z 0 E--k6-MyA r Lave, PERMIT SR#: <br />-tav1 I CA <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 #: Expiration Date: <br />Date: Contractor: IcAL <br />Signature:nn ��{( Title: <br />Printed name: ark44- <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 />TTT"` 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 numbers are, <br />CarrierC S(�(�io, JJQ Policy Number: ��Ooabt732) L <br />I certify that In the performance of the work for which this permit is issued, I shall not employ any persun 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 />"f - <br />V7 <br />!1Signature; <br />Date: <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 />($100,000.), 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 />AUTHORIZATI N FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br />1' (signature ofC•57 licensed authorized representative), <br />hereby authorize (print name) <br />to sign this San Joaquin County Well Permit Application on my behalf. I understand thls authorization Is valid for <br />one (1) year and is limited to the work plan dated on the front page of this application. <br />8-29-021 MI <br />Z'd 2Z126269TGT:01 62t7T-t7t79)02S)T 1N3WN0GNUed -i73m-nd:WmZid d90:eo 9002-9-7nf <br />