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San Joaquin County Environmental Health Services, Unit IV Well Permit Application Supplement <br />JOB ADDRESS: PERMIT SR#: <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 #: 6S ZZ 7 Expiration Date: /( e( <br />Date: ‘,6/ 24 ( Contractor: W-P1b6E <br />Signature: Title:c-57-AF,C-- Cr4OLt)(1-/S..7- <br />Printed name: ?ALA L <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 />k/ 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: .ST,A-11c- <br />I certify that in the performance of the work for which this permit is issued, I shall not employ any person in <br />should become subject to the workers' compensation provisions of Section 3700 of the Labor Code, I shall <br />any manner so as to become subject to the workers' compensation laws of California, and agree that if I <br />forthwith comply with those provisions. <br />C <br />Date: 01/2 (0 I Signature: <br />Printed Name: TALI L h6T-S60 <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 /> (C-57 licensed authorized representative), hereby <br />authorize <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. <br />5-17-2000 / MI <br />Policy Number: -1 -1"1 -7(!'"