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San Joaquin County Environmental Health Department Unit IV Well Permit Application <br /> CS/upplemental <br /> JOB ADDRESS: I ZO !N` O&�� 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#: -7Cd ?j 5-1Exp Date: <br /> t1� /� ( I,, ,� I- <br /> Date: 8 I a 5/n Contractor:GI eon jka rT Do I n 4-,12c- <br /> Signature: <br /> 1 12c-Signature: <br /> �aC Title: �� f <br /> Print Name II a nf`t <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 /> e �LL <br /> 4J a+ 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, I shall forthwith comply with those provisions. 1 11h } <br /> Exp. Date: ( /( 2--D 0 I )« Signature: - <br /> Print Name: <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 /> �,AUTHORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> rr I ty K,t 7'4e, (signatureofC-57 licensed authorized representative), <br /> hereby authorize(print name) -WAC�6 6 I?— "ifO r v I'I Me ,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/2q/02/MI <br /> WELL PERMIT APP <br /> EHO 29-01 1115107 <br />