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i11,121aQ .31a9 209463'34.3 3 FIFTH FLOOR <br />p41E 4_1.31 <br />San Joaquin County Environmental Health Services, Unit IV Well Permit Application Supplement <br />JOB ADDRESS: �JZ�� �l �0✓at; PERMIT ',SR#: aDZ9l0 `� <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 <br />d1 Professions Code and my license is in full force and ``effect. <br />License #: I @Q9D'�1 Expiration Date: `A - _ QH <br />Date:U- � - Con ractor: J `c \i\ -)n ��1 1 <br />Sianature: _ --- Title: <br />_ A 1 11 � <br />Printed name: <br />WORKERS' COMPENSATION DECLARATIiON <br />I hereby affirm under penalty of perjury one of the following declarations: (CHECK ALL THAT APPLY) <br />I have and will maintain a certificate of consent to self -insure for workers' compensation, as provided for by <br />Section 3700 of the Labor Code, for the performance of the work for whichlthis permit is issued. <br />v� 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 />4 <br />Carrier: Policy Number: _ ✓�`� "� <br />e,, 1" l.�.i'](�_ --1+� <br />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 Se. iori 3700 of the Labor Code, I shall <br />forthwith comply with those provisions. <br />Date: Signature;Ce�l I " <br />Printed Name: - <br />WARNIN,Z; FAILURE Te 6E8URE WoptReRa' 00MPENGATION ooUCi1AOC ID UriILAwFUL, AND EWA[ 191IR-IGCT <br />AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br />0100,000.), 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 />I,`�. (signature ofC-57 licensed authorized representative), <br />hereby authorize (print name} 4 L. ,I( c. _ � ' I, ajdI P n <br />to sib► 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 />5-17-20001 M1 --_ --I -- - — <br />