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06PM HP LRSERJET 3200 P•1 <br />1046 :A <br />San Joaquin County Environmental Health Services, Unit IV'Nell Permit Application Supplement <br />JOB ADDRESS: (2%�- t�ly t � �_ PERMIT SR#: a 3 7 1 <br />LICENSEE) CONTRACTORS DECLARATION (LCD) <br />1 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 #: Expiration Date: <br />Date: Contractor: <br />Signature: Title: <br />/,; <br />Printed name: �` <br />WORKERS' COMPENSATION DECLARATION <br />I hereby affirm under penalty of perjury one of the following declarations: (CHECK 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 whiIthiermitis issued. My workers' compensation insurance <br />carrier and policy numbers arCarrier: Policy Number: <br />_ I certify that in the perfor nce of the work for which this permit is issued, I shall not employ any persen 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 O/,/F,THE LABOR CODE. <br />1, L U X12. (signature ofC-57 licensed authorized representative), <br />hereby authorize (print name) lin / ff rni— <br />to sign this San Joaquin County Well Permit Application,on my behalf. I understand this authorizatlon is valid for <br />one (1) year and is Ilmited to the work plan dated on the front page of this application. <br />5-17-2000 1 MI <br />L <br />