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San Joaquin County Environmental Health Department Unit IV Well Perrnit Application Supplement <br />JOB ADDRESS: PERMIT SR: 06 6 5-6-5- <br />LICENSED CONTRACTORS DECLARATION (LCD) <br />I hereby affirm that I am licensed under the ;Nevi:ions 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*: (0573) 14 Dr7 <br />Date: I I iZE7 i b 14 Contractor: re 9 <br /> Title: Signature: ---y <br />Printed name: <br />t c) -N LA0 Expiration Date: <br />CCIY.3.PENSATION DECLARATION <br />I hereby affirm under penalty of perjury one of the following declarations: (CHECK ONE) <br />___ I hate 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 />I have and will maintain workers' ccmpensatien 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 Policy Number: 66 7)(4071L,9 I <br /> <br />I certify that In the performance of the work for which this permit is issued, I shall not employ any person in <br />J), to bec:::77.c.: .".,L.±;oct to the workers' norT?nsation 1:-Aws 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 />Expiration Date: .9 /0 Signature: <br />Printed Name: MaA" <br />WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE is UNLAWFUL, AND SI-I!..LL SUBJECT <br />AN EMPLOYER TO CRIMINAL PENALTIES AND OPAL PicoaS LIP TO ONE HUNDRED Ti C r:RS <br />(loo,otio.), IN ADOMON TO THE COST OF COMPENSATION, INTEREST, ATTORNEY'S FEES, AND DAMAGES AS <br />PROVIDED FOR IN SECTION 37as rir-2 LAiWoR CIG2- <br />AUTHORIZATION FOR OTtif2 THAN C-57 SIGNING PERMIT APPLICATION <br />t'Aat d ,sig nature ofC-57 licensed authorized representative), <br />hereby authorize (print lame) iLA • I 1.62_ cc <br />1b4s this Sa,i : Ci.'unty Well Permit Ar!.Nlicallon 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 <br />8-24:02 / MI <br />06/14/2E04 09:07 2trJablz134 3 3 FIFTH t- LUI1H <br /> t.LJ <br />EBD 29-02-001 <br />9/30C CO)