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Adr w. low- Sair Joaquin County Environmental:Health Services, Unit IV Well Permit Application Supplement JP ADDRESS: PERMITSR#.' LICENSED CONTRACTORS DECLARATION (LCD) I hereby affirm that I am licensed under the provisions of Chapter 0 (commencing with Section 7000)of Division 3 of the Business and Professions Code and rry license is it full force and effect. License GS'7 cs— Expifaticr�i Date: Date: _ 00 Contractor: Signature: cam. Title��"G�'T/D0;+�r /19anap�er� _ I t � Printed name: WORKERS COMPENSATION DECLARATION I hereby affirm under penalty of perjury one of the following declarations. (CHECK ALL THAT APPLY) _I have and m l maintain a certificate of consent to self-insure for workers'compensation, as wrov ded to,by Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. 's have anc will maintain workers'compensation insurarce, as required by Section 3700 of the Labor Ccde, `or the performance of the work for which this permit is issued. My workers compensation insurance carrier and policy numbers are. Carrier: mag/e- Policy Number: _ I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to become subject to the workers'ccmpersation laws of Califerma, and agree that if I should become subject to the workers'compensation provisions of Section 3700 of the Labor Code, I shall I orthwith comply with those prove Bions. Date: -r/" /00 Signature: A Printed Name: WARNING: FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL.AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS ($900,000.), IN ADDITION TO THE COST OF COMPENSATION,INTEREST,ATTORNEY'S FEES, AND DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR C DE. 1, � (C•57 licensed authorized representative),hereby authorize Foothill Engineering , Ervin Rif enburg to sign this San Joaquin County Well Permit Application on my behalf. I understand this authorization is valid for I one 1)year and is limited to the workplan dated on the front page of this a Ipp iration.