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San Joaquin Couu{nnttyyEE.nu�vironpppienta eal�[���3`apartment Unit IV Well Permit Application Supplemental <br /> JOB ADDRESS: if/ U �y PE RMIT SR # DS <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 <br /> �and <br /> j Professions Code and my license is in full force and effect. <br /> License#: g0c -N� A E xpnDate: <br /> Date: /a :3101 _ Contractor: K � (Y' cul rl <br /> Signature: 1 r Title: ✓ ,r -� ^-�� <br /> Print Name: F--r , .,1 i <br /> WORKER'S COMPENSATION DECLARATION <br /> I hereby affirn 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 thi s <br /> permit is issued. <br /> 1 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 an d policy numbers are: <br /> Carrier: i-+ZZ �l Policy Number. <br /> 1 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 com ply with those provisions. <br /> Exp. Date: {�� I OI Signature: <br /> Print Name: Yl— E'�'"�. <br /> —C <br /> WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT AN EMPLOYER TO <br /> CRIMINAL PENALTIES AND CIVIL FINES UP TO SLaO,000,M ADDITION TO THE COST OF COMPENSATION.INTEREST, <br /> ATTORNEY'S FEES,AND DAMAGES AS PROVIDED FOR IN SECTION 3106 OF THE LABOR CODE. <br /> WTHORI ON F ER THAN C-57 SIGNING PERMIT APPLICATION <br /> 1, (signature o C-57 licensed authorized representative), <br /> here orize(print name) ,to <br /> sign this San Joaquin county Well Permit Application on my behalf. I un erstand this authorization is valid <br /> for one year and is limited to the work plan dated on the front page of this application. <br /> 81251111211111111 <br /> END 2901 11Wa WELL PENNR APP <br />