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t 1 ' JI-tV1C1I TIU <br />San ,:oaquin County Environmental Health Department Unit IV Well Permit Appli ation Supplemental <br />_03 ADDRESS: 01515 , 1,-0-1e.y)ioiaERmiT SR # M <br />3fr)m 1 CPr 9 <br />L ICENSED CONTRACTORS CONTRACTORS DECLARATION (LCD) <br />:;eTeoy affirm that I am licensed under the provisions of Chapter 9 (commencing with Section 7000) of <br />Division 3 of the Business and Professions Code and my liCellSe IS in full force and effect <br />Exp Date - ij 3 I) 2-0 10 <br />PRCSiQtJ SAMPL-(A)67 , HjC. <br />Title L-OCA-T-10AJ 4AILY1C,EX.,_ <br />e jILEA16. .464-w uta-T) <br />WORKER'S COMPENSATION DECLARATION <br />rreoy affirm under penalty of perjury one of the following declarations (check one) <br /> i nave and will maintain a certificate of consent to self -insure for workers compensation, as <br />provided for by section 3700 of the labor Code, for the performance of the work for which this <br />permit is issued <br />nave and will maintain workers ° compensation insurance. as required by Section 3700 of Me <br />Labor Code for the performance of the work for which this permit is issued My workers' <br />compensation insurance carrier and policy numbers are• <br />A M Ertt <br />Carrier: ap LI.JES Policy Number: <br />1•1 5V441-f-d-e COMO/qt.-1 <br />i Certify that in the performance of the work for which this permit is issued, I shall not employ any <br />person in any manner so as to become subject to the workers' compensation law of California. and <br />agree that if I should become subject to workers' compensation provisions of Section 3700 of the <br />Labor Code. I shall forthwith comply with those provisions <br />-711-7 o0 Contractor <br />LJjL (cr-) <br />,to <br />af.a: Signature: <br />Print Name: tAke f•-) g-Ptv‘ii r-• pzi) <br /> <br />FAiLURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL. AND SHALL SUBJECT AN EMPLOYER TO <br />CRIMINAL PENALTIES AND CIVIL FINES UP TO $100,000, IN ADDITION TO THE COST OF COMPENSATION. INTEREST <br />A7TORNEY'S FEES, AND DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE <br />'-----7:15kUMOPR,ZATiONTOR9THER THAN C-57 SIGNING PERMIT APPLICATION - (signatur f CfR licensed auth rized rvresentative), <br />\ authorarrilTrIrlraffftr—'44144e_‘ VIAL v`-• Li <br />sigr: this San Joaquin county Well Permit Application on my behalf. I understand this authorization is valid <br />aria year and is limited to the work plan dated on the front page of this application. <br />A,7S-102/M.