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San Joaquin County En ironmental Health Department Unit IV Well Permit Application Supplement <br /> JOB ADDRESS: mW N PERMIT SR#: 0533-+3 <br /> LICEN ED CONTRACTORS DECLARATION (LCD) <br /> 1 hereby affirm that I am lic:en sod under the provisions of Chapter 9(commencing with Section 7000)of Division <br /> 3 of the Business and Prof" and my license is in full force and <br /> License#: `1a °i �J <br /> F iragon Deme: J <br /> Date: lc <br /> Slgnature• L/ . <br /> Printed name.• li 7 t <br /> ORKERS'COMPENSATION DECLARATION <br /> I hereby affirm under penalty 3f perjury one of the following dodarations: (CHECK ONE) <br /> I have and will maintain a certificate of consent to self-insure for workers'compensation,as provided for <br /> by Section 3700 of the Labor Code,for the performance of the work for which this permit is issued. <br /> 2,1 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 /> varier and policy numbersgr/e: �7 r/� <br /> Carrier. �� ' viii_, Policy Number._,� (���-�/l 1—2L2 <br /> I certify that in the performance of the 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. j <br /> Expiration Date: d f 0 Signature: (� <br /> rintad Name: <br /> Db2� <br /> WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAINF AND SHALL SUBJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> ($100,000.),IN ADDITION TO THE COST OF COMPENSATION,INTEREST,ATTORNEY'S FEES,AND DAMAGES AS <br /> PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, <br /> AUTHORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> I, (signature ofC-67 licensed aluthortzed repn entative), <br /> hereby audw ize(print name) ��L �I`)(7�Q� Z �b L(X"'gb <br /> to sign this San Joaquin County Well Permit Application an my behalf. 1 understand this authorisation is valid for <br /> one(1)year and is limited to the work plan dated on the from page of this application. <br /> 8.29-02 f MI <br /> Effb 29-02-001 <br /> 9/30/2002 <br /> E9 39dd DNI-nING MSA 809669E60Z Eb:EO B00Z/01/10 <br />