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l9 <br />San Joaquin CouW EnvirofiW4ntal Hsattih Department Unit IV Well Permit Application Supplement <br />JOB ADDRESS:!;d w b Y` PERMIT SRN SKoS T9 <br />d 5 is T 6 <br />s l i4 + <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 ft: Lc (a C 7 Expiration Date: /�(i S7 <br />r <br />Date: Cl/ Ci Contractor. <br />Signature:%�- Tftle:l(�!Y(IYi�LS"1"rcii1CC���"? <br />J <br />Printed name: N" cl 4 c4 -c— - <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 self4nsure 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 perk mtarce of the work for which this permit is issued. My workers' compensation insurance <br />carrier and policy numbers are: <br />Carrier: Policy Number. <br />6b t%"7UJ CCI <br />I certify that in the performance of the work for which this pemxt is issued, I shall not employ any person in <br />any manner so as to become subject to the worker; 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 dons. <br />Expiration Date: C' Signature: <br />Printed Name: �' U Ley <<. L (� C' G L <br />WARNING: FAILURE TO SECURE WORKERS, COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL SUBJECT <br />AN EMPLOYER TO CRIMINAL PENALTIES AND CML FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br />(1100,000.), 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 />AUTHORIZATION FOR OTHER THAN C-67 SIGNING PERMIT APPLICATION <br />(signature oIC-87 Wwwwd authorized <br />� >> representative), <br />t►ereby authorize (prkrt rams)_ ��1�f tv.� �1C� +ted li, rLk eq4 <br />to sign this San Joaquin County Well Permit Application on my "ff. I understand this authorization Is valid for <br />ons (1) year and Is limited to the work plan dated on the front page of this application. <br />6-28-021 MI <br />EHD 29-02-00) <br />6x22/04 <br />