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ss(1t1 7-13-D7 <br />i 0 <br />t• <br />/:Z1AIVI; <br />AMA <br />San Joaquin County Environmental Health Department Unit IV Well Permit Application Supplement <br />JOB ADDRESS: 3rS r. // S . lAw h PERMIT SR#: <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 Professions Code and my license is in full force and effect - <br />License #: - X(Jc�n6" <br />Date: 3 Contractor: <br />Signature: <br />Printed name: <br />Expiration Date. <br />Title: V . <br />C - <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 3 700 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 <br />. numbers are' <br />Carrier: -cJ ' wl�+U",11A Policy Number: --i <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 Section 3700 of the Labor Code, I shall <br />forthwith comply with those provisions. <br />Expiration Date: � 41 _Signature <br />Printed Name:`1�(�i--�Z^------------ <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, ATT'ORNEY'S FEES, AND DAMAGES As <br />PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. <br />AUTNQ.RIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br />hereby authorize (print na <br />Q7 <br />(signature ofC-57 licensed authorized representative), <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 />8-2S-021 <br />FHD 29-02-001 <br />6/22/04 <br />A <br />