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A 002 <br /> �Jca uln County Env ranme tb Oes,Unit 1\1 Well Permit ApRlt°atWn Su.PpFement <br /> San q 1 <br /> JOB ADDRESS: PERMIT SRS:.��� <br /> SZC <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> I hereby affirm that I am licens d under the provisions of Chapter 9 (ocrnmencing with Section 7000)of Division <br /> 3 of the Business and Profess ns Code and my license is In full force and effect. <br /> License* 10qy Expiration Date: �Z-3��XD"t <br /> Date _ ontrdetor: f - � <br /> : ` /�/t� <br /> Signature: 4w, <br /> . - 7-itPrinted name: O <br /> ORKERS' COMPENSATION DECLARATION <br /> I hereby affirm under penalty f perjury one of the following declarations: (CHECK ALL THATAPPLY) <br /> 1 have and will maintain a certificate of consent to self-insure for workers' compensation,as provided for by <br /> Section 3700 of the Labo Code, for the performance of the work for which this permit is issued. <br /> V I have and will maintain V orkers'compensation insurance, as required by Section 3700 of the LaborCode, <br /> for the performance of th work for which this permit is issued. My workers'compensation insurance <br /> carrier and policy numbe are: <br /> Carrier. C Policy Number:�3 :OO <br /> _I certify that in the perfor ante of the work for which this permit is issued. I shall not employ any person in <br /> any manner so as to be me subject to the workers' compensation laws of California, and agree that if I <br /> should become subjectt the workers'compensation provisions of Sq�tion 3700 of the Labor Code, I shat) <br /> forthwith comply with the e provisions. I <br /> Date: ` — S 0 q Signature: _ <br /> Printed Name: <br /> WARNING: FAILURE TO SECI RE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> ($100,D(0.), IN ADDIT)ON TO NE COST OF COMPENSATION, INTEREST,ATTORNEY'S FEES,AND DAMAGES AS <br /> PROVIDED FOR IN SECTION 706 OK THE LABOR CODE. <br /> I (C-57 —nshereby <br /> authorized representative), y <br /> fx Cc2 l r(Y1/?/ �7 <br /> authorize <br /> to sign this San Joaquin Cou ty Well Permit Application on my behalf. I understand this auth°rimti°n is valid for <br /> one ear and is limited to he work plan dated on the front page of Lits appticat:on^-_ <br />