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San Joaquin County Environmental ealth De rtrr��ent Unit IV Well Permit Application Supplement <br />2q?V f• ?oN) � 90:5100 9 <br />JOB ADDRESS: C Z 1/5/ t• Ater � (ice PERMIT SR#: 00 3/F_/6 <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 #: 5-1 � i Ros Expiration Date: I /.?D I /Oy <br />Date: <br />Signa <br />Printed name: C")6 <br />WORKERS' COMPENSATION DECLARATION <br />C. <br />I hereby affirm under penalty of perjury one of the following declarations: (CHECK ONE) <br />Xhave 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: 2 Q r 1 <br />Carrier: ��\v \ Policy Number: C t — J 40 2-1;_) <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 />Date: I O�� I �oZ Signature: <br />Printed Name: C 1 y 51U1�I I�1� Prone <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 />AUTHORIZA ION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br />l4 (signature ofC-57 licensed authorized representative), <br />hereby authorize (print name) o -e e✓f o - <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 />8-29-02 / MI <br />