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San Joaquin County Environmental Health Department Unit IV Well Permit ApplicationSupplemental <br /> JOB ADDRESS:8/3EDz- OR00 sr /���NCAW9 <br /> 5 <br /> PPERMIT SR# ��rd �` Z, <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> I hereby affirm that I am licensed under the provisions of Chapter 9(commencing with Section 7000)of <br /> Division 3 of the Business and Professions Code and my license is in full force and effect. <br /> License#: 15o07-3254 Exp Date: 17- Z>I Oct <br /> Date: to z c Contractor: ��� �c ll n° <br /> Q of <br /> Signature: Title: 5 <br /> Print Name:1 . (,A ),'�v L. I A <br /> It <br /> WORKER'S COMPENSATION 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 self-insure for workers'compensation,as <br /> provided for by section 3700 of the labor Code,for the performance of the work for which this <br /> permit is issued. <br /> I have and will maintain workers'compensation Insurance,as required by Section 3700 of the <br /> Labor Code,for the performance of the work for which this permit is issued. My workers' <br /> compensation insurance carrier and policy numbers are: <br /> Carrier: � � ke, III C, Policy Number: -5' <br /> I certify that in the performance of the work for which this permit is issued, I shall not employ any <br /> person in any manner so as to become subject to the workers'compensation law of California, and <br /> agree that if I should become subject to workers'compensation provisions of Section 3700 of the <br /> Labor Code, I shall forthwith comply with those provisions./ <br /> Exp. Date: lZbt.>°1 Signature:( J <br /> Print Name: ZL <br /> WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT AN EMPLOYER TO <br /> CRIMINAL PENALTIES AND CIVIL FINES UP TO$100,000,IN ADDITION TO THE COST OF COMPENSATION,INTEREST, <br /> ATTORNEY'S FEES,AND DAMAGES AS PROVIDED FOR IN SECTION 3705 OF THE LABOR CODE. <br /> A TH I TION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> (signatur t/,C/.[7 II ensad authorized representative), <br /> hereby auth ze(print name) CCtG[ Elm ,to <br /> sign this San Joaquin county Well Permit Application'6n my behalf. 1 understand this authorization Is valid <br /> for one year and is limited to the work plan dated on the front page of this application. <br /> 81291011M1 <br /> EM] i 11IS97 WEUPERAUTA <br />