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'Id/ 64/ 20b5 12' 1b 'JibbJb5bi1 UAbUAVLDKlLLiNU 1 AUL b.:.: <br />to <br />San Joaquin County Environmental Health Department Unit IV Well Permit Application Supplement <br />JOB ADDRESS: o� Wit!l�/'SI,PERMIT SR#:L� �I C�Occ <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 Suslness and Professions Code and my license is in full force and effect. <br />License #: CJ 7 -117 5 (Q Expiration Data: '3_----Q (p <br />Date: - • - 5 Co tracior. <br />t <br />Signature• <br />Title: d Ora► d n <br />{ Printed name. V t'i <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 sett -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 />X <br />1 have and will maintain workers' compensation insurance, as required by Se1ion 3700 of the Labor Code, <br />t. for the performance of the work for which this permit is issued. My workers' compensation insurance <br />carrier and policy numbers are: <br />Carrier: <br />Policy Number. <br />I certffy that in the performance of the work for which this permit is Issued, I shall not employ arty person in <br />I any manner so as to become Gubject to the worker,' compensation laws of California, and agree that if'l <br />should become subject to the workers' compensation provisio of Sect' .3700 of the Labor Code, I shall <br />forthwith Comply with those provisions. <br />Expiration Date:•` •- I - (p Signature: <br />' Printed Name: Q. •�_ <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 LAEOR CODE. <br />AUTHOR TI FOR 4_ THER THAN C-67 SIGNING PERMIT APPLICATION <br />t, <br />(signature 0fC•67 ficonsed authorized representative), <br />hereby authorize (print name) <br />to nigh this San Joaquin County Well Permit Application on my behalf. I understnnel this authorization Is vQIId for <br />one (1) year and is limited to thko work pian dated on the front page of thin application. <br />Ehn 29.02.001 <br />62210.E <br />