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San Joaquin County Environmental Health Department Unit IV Well Permit Application Supplemental <br /> JOB ADDRESS: W, 8ee641nU4-AVt,• _._. PERMIT SR# D. f f�� <br /> T J c�4, 9 53 76 <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 e ct. <br /> License#: �� 4- r r Exp Date: <br /> Date: Contractor:. ?6. <br /> Signature: Title: C- 0 <br /> Print Name: <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 /> Carrier: Policy Number: <br /> 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 1 should become subject to workers' compensation provisions of Section 3700 of the <br /> Labor Code, i shall forthwith comply with those provisions. <br /> Exp. date: r o <br /> 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 /> (signature of C-57 licensed authorized representative), <br /> hereby authorize(print nal ) t iM��� aly to <br /> sign this San Joaquin county.Weil 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 /> 81291021M1 <br /> WELLPERNT APP <br /> EHD 29-01 11W7 <br />