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• 03603 12:38pm P. 010 <br /> San Joaquin County Environmental Hpalth Department Unit IV Well Permit Application Supplement <br /> JOB ADDRESS: `(�Zf)Y.) I F2J'tL`If� PERMIT SRIF: 0o3z9S� <br /> LICENSED CONTR01ORS DECLARATION (LCD) <br /> hereby affirm that I am licensed under the provisions of Chapter 9(commencing with Section 7000)of Division <br /> 3 of the Business and Professions Code and my license is in full force and effect. <br /> License 0:5_ 5 J`~Z.I PP ,, Expiration Date: 0(!2(r Tz C>5 <br /> Date: c� Co r. �UQ� 7Ii y"�10Y kl r hn <br /> Signature: Title: ( G r/)�(1 <br /> Printed me: G 6 <br /> V{ORKERS' PENSATION 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 sell-insure for workers'cormpensation,as provided for <br /> by Section 3700 of the Labor Code,for the performance of the work for which this permit is issued. <br /> X I have and will maintain workers'compensation insurance, as required by Section 3700 of the Labor Code, <br /> for the performance of the work for which this permit is issued. My workers'compensation insurance <br /> carrier and�policynumbers <br /> �are: <br /> Carrier: ! -l11am { l Lyl Policy Number: 1.5 bq <br /> I certify that in the performance of tha work for which this permit is Issued,I shall not employ any person in <br /> any manner so as to become subject to the workers'compensation laws of California, and agree that if I <br /> should become subject to the workers'compensation provisions of Section 3700 of the Labor Code, I shall <br /> forthwith comply with those provisions. <br /> Date: Signature- <br /> Printed Name: <br /> WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CML FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> (5100,000.1,IN ADDITION TO THE COST OF COMPENSATION,INTEREST,ATTORNEY'S FEES,AND DAMAGES AS <br /> PROVIDED FOR IN SECTION 3706 OF THE LABOR GODE. <br /> AUTHORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> (signature <br /> �offC,-67�licensed authorised representative(, <br /> hereby authorize(print name) "TV �1""` Ee <br /> to sign this San Joaquin County Wall Permit Application an my behalf. I understand this authorization is valid for <br /> one(1)year and is limited to the work plan dated on the front page of this application. <br /> i <br />