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San Joaquin County Environmental Health Services, Unit IV Well Permit Application Supplement <br />JOB ADDRESS: <br /> <br />PERMIT SR#: <br /> <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 I 6 0 -7 cl Expiration Date: 7(I (0 3 <br />Date 2 /C3 4,2 Contractor: kJ-Joao A90 DRILL. No CO.1 INC. <br /> <br />Signature: • <br />'940( <br />Title: <br />Printed name: DA\J ef22-04 A5c.4- Cot <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 which this permit is issued. My workers' compensation insurance <br />carrier and policy numbers are: <br />Carrier: S40..1-e-- Policy Number: Do 2 O 238 <br />--/< I 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: 2 // 3 /6 2- Signature: 9krr <br />`Dm to 14zoG (A-rAA- <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 />I, E RI FORS s'T RCA'N (Set 44,-,elee' letkc) (C-57 licensed authorized representative), hereby <br />authorize DAVID k).-). GIZZoG <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 />Printed Name: