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ru � <br /> San Joaquin County Environmental Health Department Unit IV Well Permit Application Supplemental <br /> JOB ADDRESS: 90/O W- �ffCJ JJUL I+V-6, PERMIT SR# 6 6-�Z3 / <br /> iia C) , CA 9S33tv <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 <br /> Business and Professions Code and my license is in full force and effect. <br /> License#: c� ��y CC —ST <br /> Exp Date: <br /> Date: L o?L� Contractor: 4�? <br /> Signature: `- Title: <br /> Print Name: I 1 c. <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: c Policy Number: -� 13I9J,3-7O9 <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 comply with those provisions. <br /> / <br /> Exp. Date: lob/ / / 0 Signature: / <br /> Print Name: I" L�c-�tel. ►� <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 /> AUTHORI ON F 12 OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> I, - (signature <br /> ,o�fC-57 licensed authorized representative), <br /> h y authorize(print m EA�( �Qi i, !1 M& C']fAw 6 thYoix ,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/29/02/MI <br /> EHD 29-01 11/5/07 WELL PERMIT APP <br />