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JAHI@IqO <br />J:41 <br />San Joaquin County Environmental Health Department Unit IV Well Permit Application Supplement <br />JOB ADDRESS: #1 Port Road zi PERMIT SR#: tO $O /b/9 <br />LICENSED CONTRACTORS DECLARATION (LCD) <br />i hereby affirri that I am licensed under the provisions of Chapter 9 (commencing with Section 7000) of Division <br />3 of the Business and Professions Code ?^d my license is in full force and effect. <br />License #: SICQ - �05!4 Expiration Date:.,�� r <br />G <br />Date: � �� 01 Contractor: 1``'"' I Dvf LL C `� <br />Signature: -- -.r - �_ Title: VA Pm , I o� e, tt <br />Printed name: 1N ` <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: ^7 <br />Carrier: & Policy Number: ��j� f r ! Q� <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 />Expiration Date: Signature: 1 <br />Printed Name: <br />Wi <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 />ORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br />ofC-57 Licensed authorized representative), <br />hereby authorize (print <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 />/ MI <br />Cil l b 29-02-001 <br />6122. 4 <br />