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e v <br /> San Joaquin County Environmental Health Services, Unit IV Well Permit Application Supplement <br /> JOB ADDRESS TSD l�Z �i&r- &C(- PERMIT SR#_ <br /> Ch <br /> LICENSED CONTRACTORS DECLARATION (LC) <br /> hereby affirm that I am licensed under the provisions of Chapter 9 (commencing with Section 7000)of Division <br /> 3 of the Business and Professions Code and my license is in full force and <br /> effect. <br /> License#: l Gf�l(� 7 -- Expiration Date: <br /> Date: -1I .� ontractor: ! C <br /> 2,v,�5 <br /> Signature: (( f1 Title: <br /> Printed name: Joh 1 A . V, <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the following declarations- (CHECK ALL THAT APPLY) <br /> I have and will maintain a certificate of consent to self-insure for workers' compensation, as provided for by <br /> Section 3700 of the Labor Code. for the performance of the work for which this permit is issued. <br /> I 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 /> carrier and policy numbers <br /> ��are: q <br /> Carrier; �Cc i��t � Policy Number:�13'9 J (�Y1 --5334-- <br /> I <br /> 334- — <br /> I certify that in the performance of the work for which this permit is issued, 1 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 J <br /> should become subject to the workers' compensation provisions of Section 3700 of the Labor Code, I shall <br /> forthwith comply with those provisions. n <br /> Date: ?_AIo Signature: �-C• <br /> Printed Name' • ��t �( n1 — <br /> WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT <br /> AN EMPLOYER TO CPoMINAL 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 /> 1, (C-57 Licensed authorized representative), hereby <br /> authorize Or <br /> to sign this San Joaquin County Well Permit Application on my behalf. I understand this authorization is valid for <br /> one(1)year and is limited to the work plan dated on the front page of this application. <br /> .d WO2J3 Hvvs:0 1 666 1-VO-0 L <br />