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San Joaquin County Environmental Health Services, Unit IV Well Permit Application Supplement JOB ADDRESS: 5?4- PERMIT SR#: 4�4Z5f�� LICENSED CONTRACTORS DECLARATION (LCD) I hereby affirm that I am licensed under the provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code and my license is in full force and effect. License #: Date: Signature: _ Printed name: Expiration Date: Title: RKERS' COMPENSATION DECLARATION I hereby affirm under penalty of perjury one of the following declarations: (CHECK ALL THAT APPLY) _ I have and will maintain a certificate of conse elf -insure for workers' compensation, as provided for by Section 3700 of the Labor Code, for th rformance of the work for which this permit is issued. I have and will maintain workers compensation insurance, as required by Section 3700 of the Labor Code, for the performance of the work for which th' permit s issued. My workers' compensation insurance carrier and policy numbers are: Carrier:licy Number: I certify that in the perfoYnance ofyte or which this permit is issued, I shall not employ any person in any manner so as to become subjworkers' compensation laws of California, and agree that if I should become subject to the worensation provisions of Section 3700 of the Labor Code, I shall forthwith comply with those provis Date: Signature: Printed Name: WARNING: FAILURE TO SECURE W RKERS' COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENA IES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS ($100,000.), IN ADDITION TO THE CO T OF COMPENSATION, INTEREST, ATTORNEY'S FEES, AND DAMAGES AS PROVIDED FOR IN SECTION 3706 THE LABOR CODE. (C-57 licensed authorized representative), hereby authorize �eo2GE (ON V �-SE 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 page of this application. ' 5-17-2000 / MI