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n Jones 5-9451 I'• Z <br />0/U F o iAe-2 <br />'rWn3 fid, �9 j -$),e� " <br />San Joaquin Coun y Environmental He Ith Services, unit 1V Well Permit SupplementAppllca�vn <br />1116 3 LSO evam [ f 1 <br />JOB ADDRESS: ioD �o PERMIT SR# G J <br />�w <br />LICENSED CONTRACTORS DEC1ARAtYdN (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 />License P _lA?� L 5 Expiration Date: <br />Date: 4- 1 Z -`O Contractor: RC CXA Efr \1 <br />Signature: _ �l L_1L Title: <br />Printed name: <br />WORKERS' COMPENSATION DECLARATION <br />I hereby affirm under penalty of perjury one of the following declarations: (CH ECK ALL THAT APPLY) <br />_ I have and will maintain a certificate of consent to self -insure for workers' compensation, as provided for by <br />Section 3700 of the Labor Code, 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 />Policy Number: g:-, 36 <br />Carrier: <br />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 />Date: Signature: <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 />($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 />licensed authorized representative), hereby <br />authorize- <br />to <br />uthorizeto sign this San Joaquin County Well Permit Application on my behalf. 1 understand this authorization Is valid for <br />one (1) year and is limited to the work plan dated on the front page of this application. <br />5-17_-20001 MI <br />cc#,cQQhC07 l c : t Q TGIGi7. /7T /b0 <br />