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Ftan Joaquin County Environmental Health Department Unit N Well Permit Appl►cation Supplement <br /> JOB ADDRESS:� PERMIT SRO: <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> t he reby affirm that I am It tensed under the provisions of Chapter 9(commencing With Section 7000)of Division <br /> 3 of the Business and Professiorts Code and my license is in fill[force and effect. <br /> Lice nse Expiration Date: <br /> 2 f <br /> o e-'� ConVactor. <br /> Signature: <br /> Prir tee!name: <br /> WORKERS'COMPENSATION DECLARATION <br /> I he eby affirm under pena Ity of perjury one of the following dederations: (CHECK ONE) <br /> I have and will rnainta n a certificate of consent to self-insure for workers'compensatlon,as provided for <br /> by Section 3700 of the!Labor Code,for the performance of the work for which this permit is issued. <br /> have and will mainta n workers'Compensation insurancs,as required by Section 3700 of the Labor Code, , <br /> for the performance of the work for which This permit is issued. MY WCrkers'c=p6maticn itisuranca <br /> terrier and policy numbers are: /1 <br /> t;arrier. J t Policy Number -7-Atoe / c !—7 <br /> rxrtify that in the performance of the work far which this permit is issued. I Shall not employ any person in . <br /> rty manner so as to becorre subject to the workers,compensation lacus of Califrmia,and agree that if f <br /> should baeorrte subject to the uvorkees'cnmpensWJen provisions of Seo on 270C c: i <br /> oriihwith c rttpty with t�ose provisions. snail <br /> Yr Ccde, <br /> aDate: <br /> i gag nature: <br /> Printed Nance' �taj <br /> �� . <br /> WAR 4tNG:FAJLLJRE TO SE---L7R61NORKERS'COUPENSA7ION COVERAGE IS UNLAWFUL.AMD SHALL SUBJEC- <br /> AN E;9PLOYER TO CRIMWC,L PENALTIES AND CNIL.FIXES up TO ONE HUNDRED THOUSAND DOLLARS <br /> (5140,300.),W AD13MON TC THE COST ap CCUpENSATION,INREST,ATTORNEY IS FEES,AND DAMA+'a>:S AS <br /> PROI gDED FOR IN SECiI01.1 37ag OF THE LABOR C—IDE <br /> THOR17ATION FOR OTHER THAN C-67 SIGNING PERMIT APPUCATION <br /> �- 1 d <br /> (signafthre Otic-37 lleensed authorized repnesenta*m), <br /> hereby authorize(minthne=11GZZ'�. Gl <br /> to sig 1 this San Joaquin County Wed Permit Application on my behaM 1 understand this authorization is valid for <br /> Lf!one )yearand fn Grnitedin the worts Plan dated on the front page of this appileatiom <br /> z Mil <br />