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San Joaquin County Environmental Health D artment Unit IV Well Permit Application Supplement <br />JOB ADDRESS: l� y PERMIT SR#: �O/ %062, <br />L ENSED 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 #: V/ �p Expiration Date: i—ILlc s 2,' UC3 <br />Date: () ' IC ractor: GOC�0 LOf1 ') totltr <br />Signature: Title: toric -(VNc`r CG ,yr <br />Printed name: 1\C\ R Q eCk_ <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 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 />Carrier: nhv5� Policy Number: `NC <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 thos provisions. <br />Expiration Date: ), Q Signature: <br />o t 0 Printed Name: (1\CX <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 />AUTHORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br />Ate/ I`-,eec.P _ (signature ofC-57 licensed authorized representative), <br />hereby authorize (print name) 5: <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 />8-29-02 / MI <br />EHD 29-02-001 <br />6/22/04 <br />