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• i <br /> Dn I Unit IV Well Permit Application Supplemental <br /> 109 ADDRESS _ (......Ci1� / VP _ PERMIT SR air <br /> s ,14 V, f <br /> f �9 <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> i hereby affinn that I am licensed under the provlslons of Chapter 9 {commencing with Section 7000)of <br /> Division 3 of the Business ,and Professions Code and my license is In full force arid effect <br /> License # Exp Date <br /> Date "w Contractor 5 CA S lS I <br /> Signature Title <br /> Print Name t4tiJ G 1 <br /> WORKER'S COMPENSATION DECLARATION <br /> I hereby affirm under penalty of penury one of the following declarations (check one) <br /> I have and will maintain a certificate of consent to seff-insure for workers" compensation. as <br /> provided for by section 3700 of the labor Code for the performance of the work tot 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 worfnis <br /> compensation insurance carrier and policy numbers are <br /> Carrier: 'i tEGaALTI rr Policy Number: ��C1} <br /> i certify that In the performance of the work for which this permit �s 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 $ub}ect to workers'compensation provisions of Section 3700 of the <br /> Labor Code i shall forthwith Comply with those pro is on$ <br /> t xp. Date.. _._. Signature; -- <br /> Print Name: d `e 1 Ps tt11 dj <br /> WARNING.. FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE is UNLAwfUL,AND SHALL SUBJECTAN EMPLOYER To <br /> CRIMINAL.PENALTIES AND CIVIL PINE$UP TO$100,000.rN ADDITION TO THE COST Of COMPENSATION..INTEREST, <br /> ArTORNEY'S FEES,AND DAMAGE:5 AS PROVIDED FOR FN SECTION 7706 OF'rHE LABOR CODE <br /> U 2ATtON FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> } -------^""""" Islgnature of C.§T licensed auth +z representahve), <br /> hereby authorize ipr}nt Hamell�l.!..LCeLY CJ t� K S l"tt'';z p 1Jt 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 />