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SanQM�Qquin County Environmental) Health Department Unit IV Well Permit Application Supplemental <br /> J 1�4DDRESS: �L�Z4 Uf Cq4?:: PERMIT SR # <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#: Exp <br /> Date: l l,, I <br /> Date: �'I��� Contractor: N -' T keA R'C4 �rl d II1Ci r/!G <br /> Signature: 6uIt&&IllJ� Title: bt, in Ll�/YL/ 414, , <br /> Print Name:J err l 1,(J 1 <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 /> Ski lei t� <br /> Carrier. � Policy Number: <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 <br /> /J I shall forthwith comply with those provisions. <br /> Exp. Date: l / U C? )-LUSignature: 10" <br /> Print Name: -A(?irr-t' UA .-k <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 3706 OF THE LABOR CODE. <br /> I, IA THORI�ZP TIO�7u:,,FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> +rCr\ W I `� (signature of C-57 licensed authorized representative), <br /> �( <br /> hereby authorize(print name) 6 E(L �d- ►�N , 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/29/02/MI <br /> EHD 29-01 11/5/07 <br /> WELL PERMIT APP <br />