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V `$0 Joa`gtiin County Environmental Health'Services, Unit IV Well Permit Application Su ILI JOB ADDRESS: 4T-,2 0 E`� S PERMIT SR#• LICENSED CONTRACTORS DECLARATION (LCD) I hereby affirm that I am licensed under the provisions of Chapter 9 (commencing with Section 7000) of D 3 of the Business and Professions Code and my license is in full force and effect. License #: Date: Signature: Printed nar Expiration Date: WORKERS' COM PENSATPN DECLARATION I hereby affirm under penalty of perjury one of ing declarations: (CHECK ALL THAT APPLY) I have and will maintain a certificate onsent to self -insure for workers' compensation, as provided for by Section 3700 of the Labor Code, f the performance of the work for which this permit is issued. _ I have and will maintain for the performance of t carrier and policy numt Carrier: �6rs' compensation insurance, as required by vork for which this permit i i ue . My worke are: P)11icy um io O of the Labor Code, mpensation insurance I certify that in e performance of the work for which th permit is issued, I shall not employ any person in any manner o as to become subject to the workers'compensation laws of California, and agree that if I should be me subject to the workers' compens on provisions of Section 3700 of the Labor Code, I shall forthwith omply with those provisions. Date: Signature: Printed Narr1k WARNING: FAILURE TO SECURE WORK RS' COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTI S AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS ($100,000.), IN ADDITION TO THE CO OF COMPENSATION, INTEREST, ATTORNEY'S FEES, AND DAMAGES AS PROVIDED FOR IN SECTION 3706 O THE LABOR CODE. 1, / (C-57 licensed authorized representative), hereby auth to sign this San Joaquin County Well Permit Application on my behalf. I understand this authorization is valid for one (1) year and is limited to the work plan dated on the front of this application.