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A t/1" 1 .9, wvl- g �?�, <br />San Joaquin County Environmental Health Department Unit IV Well Permit Application Supplement <br />1__12.ZF s",ooel& (.-32 <br />JOB ADDRESS:-- 2zsz �t°L��. 1 ve.vy�a�, i" PERMIT SR#: --12(2V&&22 <br />LICENSED CONTRACTORS DECLARATION (LCD) <br />1 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 #. C S ` 7 17 S 10 <br />Date: 5 ~ — U ("�—Contractor: <br />Signature: �Z�2 <br />�/ (� <br />Printed name: f� P/A � 1 <br />Expiration Date: 1-31-08 <br />ca.c -e Dri I I i", I nc. <br />Title: 019�7 . M <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: �-Cj N 1 �Q ��'� Policy Number; <br />I certify that in the performance of the work for which this permit is issued, t 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 Se i n 3700 of the Labor Code, I shall <br />forthwith comply with those provisions. <br />Expiration Date: S i ` 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 LABOR CODE. <br />AUT ORIZAT R OTHER THAN C-57 SIGNING PERMIT APPLICATION <br />1. (signature ofC57 licensed authorized representative), <br />hereby authorize (print name) <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 />i 8-29-021 MI <br />1:11D29 -02 -ml <br />N22/(m <br />