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7- 1 3- D 7; / i i 1 ^N1 ; <br />J A IVII I @ I P, 0 <br />b <br />^I <br />��sf � <br />/r� <br />e1 <br />r C <br />San Joaquin County Environmental Health Department Unit IV Well Permit Application Supplement <br />JOB ADDRESS: 3yS c ///45;W.l PERMIT SR#: 4D 1.361 <br />00 52-3F6 <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 #: <br />Date: ��/ 3 ��\ Contractor: <br />Signature: <br />Printed name: <br />Expiration Date;_ /�I�'__ <br />ti— Title: V. <br />L <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 3700 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 numbers are: dr <br />Carrier: f Policy Number: <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 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: R1IJQT--J- _ Signature`�_.------- <br />Printed Name:. <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, ATTORNEY'S FEES, AND DAMAGES AS <br />PROVIDED FOR IN SECTION 3706 OF THE LA13OR CODE. <br />TION FOR OTMER THAN C-57 SIGNING PERMIT APPLICATION <br />ofc-,911icensed authorized representative), <br />her®by auth <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 />B-29-021 <br />EHD 29-02-001 <br />6/22/04 <br />