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L.c17 '‘k r <br />1 4 <br />San Joaquin County Environmental Health Department Unit IV Well Permit Application Supplement <br />JOB ADDRESS: 10 2.a.Sr ,21"-\ 5112--ce,liTfc..c,) PERMIT SR#: C031155 <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 />Expiration Date: \ 131 )0 (.1 <br />(-)(2-U1 9 D12-)1h A)Cj <br />Signature: Title: eirerCeifi9;€21- /7740recIeree-• <br />Printed name: Chas" /- ge//1 er - <br />WORKERS' COMPENSATION DECLARATION <br />I hereby affirm under penalty of perjury one of the following declarations: (CHECK ONE) <br />KhaVe and will maintain a certificate of consent to self-insure for workers' compensation, as provided for <br />by Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. <br />(\C 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: G .,$ '11 Policy Number:C. 9 MOti* E./4.-r <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: --Clr 9 io="3- Signature: <br /> <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 DL,LLARS <br />($100,000.), IN ADDITION TO THE COST OF .COMPENSATION, INTEREST, ATTORNEY'S FEES, _VD DAMAGES AS <br />PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. <br />AUTHORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br />I, Ci-per_y• lerter fi'47 Cc (signature ofC-57 licensed authorized representative), <br />hereby authorize (print name) <br />to sign t4ip San Joaquin County Well Permit Application on my behalf. I understan4 this authqrization is valid for <br />one (1) year and is limited to the work plan dated on the front page of this application. <br />8-29-02 / MI <br />License #: <br />Date: Contractor: