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JAIAMIA0 <br />1Zj�� <br />San Joaquin County Environmental Health Department Unit IV Well Permit Application Supplement <br />JOB ADDRESS: // S3o cJ C/r'Hy Mica k -h, PERMIT SR#: D.6?'�F Z/ <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 #: -110 0-7 q Expiration Date: 0 -13-3 q ' <br />Date: 10136161 Contractor; _ INDD�wfi P 1)124 Lr�( <br />Signature: Lam?-�� (!f fir% Itle: I�ESlD6U$` <br />V <br />Printed name: _tea arE, I,Uoa u r� <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: <br />Carrier: �TAT-C— aA.4) Policy Number, 00 ZO Z3,y — Z00 <br />1 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: 14012-66 6 Signature: <br />Printed Name: COIVC(NC-r Cy, WyrjOi,4107et <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 LABOR CODE. <br />AUTHORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br />(signature ofC-671icensed authorized representative), <br />hereby authorize (print name) I ODD ffr4,� <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 />8-29-021 MI <br />MM 29-02-091 <br />6122/04 <br />