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Sati jbakuin County Environment-all-lento,- •Servicic, UI tiV Well Permit i.pplitzition Supplement <br />Joli ADDRESS; 1c;i417 Cini &Li oc, 6 S-7-4,tc-r PEOMIT, $1;t#: 06D2(0, <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 />License #: 7/ 0C) 7 (i Expiration Date: 07 — CD i <br />Date: C4I / /00 Contractor: (400060.4ieo 2 iLL4rJC C-7 ZeVe. <br />Signature: Title; <br />Printed name: it) Cy Al G— J LcJ C). Z.) L-t) /9-8 <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 />,X 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. r/7.4,17I rif Policy Number: Sr, 6_001 9 "1-77,413-04 <br />certify that In the performance of the work for which this permit is issued, I shall not employ any person in <br />any mariner so as to become subject to the workers' compensation laws of California, and agree that if <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 />(5100,000.), 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 />-57 licensed authorized reprysentatIve), hereby <br />authorize ePae knoiJ 414-14 <br />to sign this San Joaquin County Well Permit Application on my behalf. I 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.