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2,- R <br /> kE <br /> San Joaquin County Environmental Health Department Unit IV Well Permit Application Supplemental <br /> 2 <br /> v.p- R• . R•0. Lo. Nw4ir, <br /> JOB ADDRESS: 0�r f0a &P_1L1&1Ltt _ PERMIT SR# O Sof <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.he <br /> License#: O 6a 3 3 c4 Exp Date: i�d 1 <br /> Date: d8 Contractor: SZ art L U/'r� <br /> Signature: 0. Title: <br /> Print Name: 1AJJ" <br /> WORKER'S COMPENSATION 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 /> Carrier: Policy Number: —] 12)15 5 3 ']0(.P <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 hall forthwith comply with those provisions. <br /> Exp. Date: �o�/ /0-8, Signature: / <br /> Print Name: W, <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 /> A I TION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> I � (signature of C-57 licensed authorized representative), <br /> ereby authorize ( int name) G-,LMARE ,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 /> S/29102/MI <br /> WELL PERMIT APP <br /> EH D 29-01 11/5/07 <br />