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0 0 <br /> San Joaquin County,AN <br /> Health Department Unit IV Well Permit Application Supplemental <br /> JOB ADDRESS: A t4 al-aro- d I PERMIT SR# b o M S� <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> I hereby 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 license is in full force and effect. <br /> License#: to 3 4P 3 S 7 Exp Date: I/3 ),1,4012- <br /> Date <br /> 1,4012Date: (0 1111 to Contractor: PKIFC4SIon) SAP10w,06 JAIG <br /> Signature. al=== Title: LOCA-"r70n1 MA+tJ/}6E7C <br /> Print Name. GREriL4 r-w-4L ena-b <br /> WORKER'S COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the following declarations: (check one) <br /> I have 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 /> I have and will maintain workers'compensation insurance, as required by Section 3700 of the <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 /> AMER14� )nJTEItw1A-Tlga/}L <br /> Carrier: SPE�IAt,.7tn LINES Policy Number: _ � 342-1112- (CA-) <br /> 15vljl ti— E 1DhlJM.7I <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 Cairfomia, 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 pro (dons. pA pp <br /> Exp. Date: 1a13012,0)O Signature: QYX �--- <br /> Print Name: Iii wo m c4uwFog-D <br /> WARNING: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 /> ATTORNEY'S FEES,AND DAMAGES AS PROVIDED FOR IN SECTION 1706 OF THE LABOR CODE. <br /> U 2ATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> I, (signature of 57 liceriped` au ' ed representative), <br /> hereby authorize(print name) i Yl ,to <br /> sign this San Joaquin county Well Permit Application on my behalf. I understand this authorization is valid <br /> for one year and is limited to the work plan dated on the front page of this application. <br /> R/MONMI <br /> FMDALi ItfiW] <br /> *ELL➢ ITNro <br />