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San ,loaguln GOunty Environmental �Aeiagjh Services, Unit lel Well Permit F pplicatfan ��l men! <br />JOB AIDDRESS: <br />'..1 PERMIT SR9: <br />LICENSED CONTRACTORS DECLARATION (LCD) <br />I t Hereby affirm that I am licers&d under the provisions of Chspter 9 (axr,mencing with Sectior. 7000? of CivisrO:'� <br />3 of the Business and Prufesslons Code and my {Icen,3e is in fuli force and effect. <br />License 9: 4 "11 <br />,-.7 1 ` <br />j Date. <br />I <br />j signature: <br />jPrinted nam®: <br />i <br />i <br />I <br />>< r�� C . <br />Title' — <br />WORKERS' COMPENSATIQN DECLARATION <br />I heraby affirm under penalty of perjury one of the folio•riino deciarnons (CHECK ALL THAT APPLY) <br />I have and will maintain a certificate of consent to self nsure for workers' )0M0en5aLion, as Provided for by i <br />/ Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. <br />I havc ahyAll rnworkers' orkers' compensation insurance, as eyuired by Se^ tion ersatiort2700 oft nasu o <br />a cevJd~c <br />for the perforr„ante of the work for which this parmit is IssuFd. My wori<er ornp <br />carrier and policy numbers are: <br />Policy Number: �•�� _ � -/ -n -`�1 <br />Carrier: <br />i <br />I I certify that in the perfotrr.ance of the work for whirl, this permit .s issued, t shz:1 not employ any person in <br />any manner so as to 5ecome subJec to t` a workers' compensation laws of California, and agree that it I i <br />should become Subject to the workers compensation provisions o` Section 3700 of the Labor Code. I shall <br />forthwith tcor,-.pty with those provisions- <br />_/�I tate: � 1� Signature: y <br />Printed Name:�_I-:-�'�-- l <br />WARNlrv3- FAILURE TO SECURE WORKERS' C0h1PEN5A(ION COVERAGc :S Ut:tsANiFUL. I ?:a S!?AL,- SUBJFC.T <br />AN cIV1PLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br />($100,000.), IN ADD�T)ON TO THE CG�ST OF <br />SECTION 3TUS Q THE LABOR CODEION, INTEREST, ATTORNEY'5 FEES, AND DAMAGE SAS <br />PROVIDED FOR 1 I <br />{G 6T licenced' uthar d representative), hereby I <br />lU r G <br />authcrlxa <br />to Sign this $an Joaquin •C UntY Well Bern'°: ApplraaGon on my pehalf. I undorstasld this -authorization is valid fol <br />one b tt� work tan dated on the (rout page of this app ' <br />(1 j year and is llmfted <br />