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WJ A6vIt. <br />San Joaquin County Environmental Health Department Unit IV Well Permit Application Supplement <br />JOB ADDRESS: (r,yya LU. 9i41vNG9- Ave, PERMIT SR#: � �/ 2-11 <br />GDDi ,C,A- 9511y Jr <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 Expiration Date: NOV Q,., h e,- Z a .3 <br />Date: Contractor: / QA a c✓) u, f f'M PO <br />Signature: Title: 1D D � EC / lT �E a <br />Printedname: l%M4Tl`%-/ J, �UFl�•�1� <br />WORKERS' COMPENSATION DECLARATION <br />I hereby affirm under penalty of perjury one of the following declarations: (CHECK ALL THAT APPLY) <br />_ I have and will maintain a certificate of consent to self -insure for workers' compensation, as provided for by <br />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 />5TATF_ CaMple��iQ� ,,22 `' pG-�, Zoo3 <br />Carrier: �N <br />vP CR, F U N D Policy Number: J 5/% 7 %VI <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 />Date: T1 I O Z_, Signature: <br />Printed Name:,,,,/�(i Cv <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 />I, (signature ofC-57 licensed authorized representative), <br />hereby authorize (print name) <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 />1-25-02/ MI <br />