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�V <br />al/07/23R4 10:21 9168610430 <br />SECOR <br />6�VE; 3 <br />San Joaquin County Environmental Hfealth Department Unit IV <br />JOB ADDRESS:�D �% ee <br />PAGE 02/02 <br />1 Permit Application Supplement <br />PERMIT SR#: 00 /- /- <br />LICENSED CONTRACTORS DECLARATION (LCD) <br />I hereby affirm that I am licensed uncle, the provisions of Chapter 9 (commencing with Seolion 7000) of Division <br />3 of the Business and Processions Code and my license is In full force and effect. <br />License # CS 7 Y�lC-f" Expiration Date / / 3 / / 6 <br />Cala <br />Contractor: <br />Signature: //1AQ Title: Lr/O%LS �a��1190 <br />Printed name: C, e"Al a&C 00AP./' <br />WORKERS' COMPENSATION DECLARATION <br />1 hereby affirm under penalty of perjury one of the following declarations: (CHECK ONE) <br />1 I have and w'II maintain a certif:ate of consent to self4nsure for wori<ers' compensation, as provided for <br />by Section 3700 of the labor Cade, 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 />Carrier: 6Si77 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 3703 of the Labor Code, I shall <br />forthwith camp <br />/ywiith those provisions. <br />Date: b%/U/ Signature: <br />Printed Name: 6!ie Ci' (/!'�I/i�� <br />dr <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 3708 OF THE LABOR CODE. <br />AUTHORIZATION FOR OTHERTHAN C-67 SIGNING PERMIT APPLICATION <br />rr"-&1ZC&WA N911111111itfif, (siiggnnatuur8 ofC-67 licensed authorized repmeentative), <br />hereby authorize (print name) %-iQO <br />to sign this Sen Joaquin County Well Parmk Application on my behalf. I understand this authorization Is valid for <br />one (11 year and Is limited to the work pian dated on the front page of this applloation. <br />B-29.42 l MI <br />z - d 0026 1317N3Sd-1 JH Wc10Z=V �100Z 80 NdC <br />