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mac, 2 099636 9 60 <br />i <br />1 <br />�P b� <br />San Joaquin County Environmental Health Department Unit IV Well Permit Application Supplement <br />JOB ADDRESS: 3 15 F !/ r4 PERMIT SR#: <br />1 <br />LICENSED CONTRACTORS DECLARATION LCD)' <br />I hereby affirm that I am licensed under the provisions of Chapter 9 (commencing with Secbon 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—( (D I 1 Contractor. Cn ✓ . �U w tr-.:Z ,��:s �„ <br />i Signature: <br />Title: <br />Printed name: <br />1 <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 />1by Section 3700 of the Labor Code, for the performance of the work for which this permit is issuedr <br />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. _ s� l -E � Policy Number: J 4 r -f Z <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 Califomia, and agree that if 1 <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 />Expiration Date: On Signature: \ <br />Printed Name:----_-ln�— — ----- <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 />($1 D0,000.), 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 />(( {signature oFC-)57 authorized representative), <br />hereby authorize (print name) �u b <br />to sign this San Joaquin County Well Permit Application on my behalf. 1 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-DOI <br />6/22/04 <br />P. 1 <br /># 2/ 2 <br />