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pjtp _4 <br /> San Joaquin County Environmental Health Department Unit IV Well Permit Application Supplemental <br /> Br* <br /> JOB ADDRESS: Z_ 65���O t 5' r* PE RMIT 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#: 7Soa. -SL-1 E xpy�Date: 1 31 <br /> Date: 7�ca�3 ��_� �,.. Contractor: �r/S'�' - "✓° tt--ir 'N <br /> Signature: E Title: <br /> Print Name: , - ERj I <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 <br /> (carrier an d policy numbers are: 1 <br /> Carrier: 4 ttiti��� Policy Number: <br /> I certify that in the performance of the work for which this permit is issued, 1 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 com ply with those provisions. <br /> Exp. Dater �v Signature: 1 74 vlt _ <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 /> AUTHO TION F THEIR THAN C-57 SIGNING PERMIT APPLICATION <br /> 1 (signatur of C-57 licensed authorized representative), <br /> her rn a(print name__ D —" " ` ,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 /> ArMO 7Mi <br /> EH029 111E 7 WDI-PERMIT APP <br />