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San Joaquin County Environmental Health Department Unit IV Well Permit Application Supplemental <br />JOB ADDRESS: PERMIT SR # OST �3S <br />LICENSED CONTRACTORS DECLARATION (LCD) <br />I hereby affirm that I am licensed under the provisions of Chapter 9 (commencing with Section 7000) of <br />Division 3 of the Business and Professions Code and my license is in full force and effect. <br />License #: 7 I� v 15 I Exp Date: I— ✓ I � o <br />Date: V5 — I Ci 0 <br />Signature: <br />Contractor: CC1scad e- Y1 L <br />Print Name: i C Y J a ra ►vL (I I C) <br />Title: C� h <br />WORKER'S 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 <br />provided for by section 3700 of the labor Code, for the performance of the work for which this <br />permit is issued. <br />V I have and will maintain workers' compensation insurance, as required by Section 3700 of the <br />Labor Code, for the performance of the work for which this permit is issued. My workers' <br />compensation insurance carrier and policy numbers are: <br />Carrier:A � m�;yA N0,-�iQ yla ( Policy Number: COEt Xl �13 I <br />I certify that in the performance of the work for which this permit is issued, I shall not employ any <br />person in any manner so as to become subject to the workers' compensation law of California, and <br />agree that if I should become subject to workers' compensation provisions of Section 3700 of the <br />Labor Code, I shall forthwith comply with those provisions. <br />Exp. Date: V? I — Signature: <br />Print Name: <br />WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL SUBJECT AN EMPLOYER TO <br />CRIMINAL PENALTIES AND CIVIL FINES UP TO $100,000, IN ADDITION TO THE COST OF COMPENSATION, INTEREST, <br />ATTORNEY'S FEES, AND DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. <br />AUT SOI F OTHER THAN C-57 SIGNING PERMIT APPLICATION <br />I, (signature of C-57 licensed authorized representative), <br />hereby authorize (print name) 4to <br />sign this San Joaquin county Well Permit Application on my behalf. I understand this authorization is valid <br />for one year and is limited to the work plan dated on the front page of this application. <br />R/29102/Mi <br />EHD 29-01 11/5/07 WELL PERMIT APP <br />