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San Joaquin County Environmental Health Services, Unit IV Well Permit Application 5upplernent <br />Q'AQDRESS: r C&A &6tRMIT SR#:�v2 Z <br />LICENSED CONTRACTORS DECLARATION (LCD) <br />I hereby affirm that I am licensed under the provisions of Chapter 9 (commencing with Sectio, 7000) of Division <br />3 of the Business and Professions Code and my license is in full force and effect./ <br />License #: S 7 Expiration Date: <br />Date: Contractor: - 1 <br />Slpnature: � Title: „f'd&�'naa� <br />Printed name: <br />WORKERS' COMPENSATION DECLARATION <br />1 hereby affirm under penalty of perjury one of the following declarations: (CHECK ALL THAT APPLY) <br />Xhave and Will maintain a ceftificate of consent to self -insure for workers' compensation, 8S provided for by <br />Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. <br />-9I have and will maintain workers' compensation Insurance, as required by Section 3700 of the Labor Code, <br />for the pedorman a of the work for which this permit is issued. My workers' compensation insurance <br />carder and policy numbers are: <br />Carrier: a'GL i Policy Number: <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 />Dane: �f Signature: &LOtte <br />_ n <br />Printed Name: <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 />($i0, PROVIDED FOR , IN ADN ADDITION <br />TO THE COST OF 3706 CF THE COMP NSA ION, INTEREST, ATTORNEY'S FEES, AND DAMAGES AS <br />SECT <br />I, �(�. pr iTI'ul)t?.d'' (signature ofC-57 licensed authorized representative), <br />hereby authorize (print name) kl,�2 me 'e Z <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 applicatlon. <br />5-17 <br />Z/ l abed <br />rUl <br />`ev:OI 10-8Z-bnd `ZOSO CLE SZ6 `'QUI `bUT;Sal 'g bUTTTTUQ bbaJO :/<S ;u@S <br />