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A <br />J A V I @,� <br />San Joaquin County Environmental Health Department Unit IV Well Permit Application Supplement <br />JOB ADDRESS:_ X15 'v24 -A y d vt2i, A jV O PERMIT SR#: DS3S/9 <br />ST0CKTo,,.l CA <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 />r <br />License #: _ bi oo Expiration Date: har �G c�� �-� <br />Date: _ZS sJ —S,q . Z1 Contractor: Alva r c' D cf `nom; f1 f„SMC T171 1 nC <br />Signature: z �� A_,At— Title: � Of c j Cho /o (, 1,37 <br />Printed name: <br />\./El)q <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 />.- 1 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 />-EnS . <br />Carrier:dv102")Sc bion Fv,,,O Policy Number: �1 I 7ll <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 />ExpirationDate: 2 ()C 0 <br />p Signature: <br />Ex <br />Printed Name: /I 4nTh9 N/ ,iCV ��Ag <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 />AUTHORIZATION FOR OTHER THAN C-57* NING PERMIT APPLICATION <br />(signature ofC-57 licensed authorized representative), <br />hereby authorize (print name) <br />to sign this San Joaquin County Well Permit Ap cation on my behalf. I understand this authorization is valid for <br />one (1) year and is limited to the work plan ted on the front page of this application. <br />8-29-02 / MI <br />EHD 29-02-001 <br />(,mina <br />