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San Joaquin County Environmental Health Department Unit IV Well Permit Application Supplemental <br /> JOB ADDRESS: 15 01 W. 3 C.WWPERMIT SR# <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#: —406 S627 Exp Date: <br /> Date: l-ek-09 Contractor: <br /> Signature: _-Imeu—�w Title: �MD <br /> Print Name: V�trtr!t Z, (6�t�Ci%NS0 <br /> WORKER'S COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the following declarations: (check ones <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 /> X 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: S AtJC ck Policy Number: <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 sh 1 forthwith comply with those provisions. <br /> Exp.Date: 4ql-0 Signature: <br /> Print Name: <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 3706 OF THE LABOR CODE. <br /> AUTHORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> 1, 3,t%ffi m (signature of C-57 licensed authorized representative), <br /> hereby authorize(print name) S -M 1'1 1. ,to <br /> sign this San Joaquin county Well Permit Application on my behalf. I 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 /> B1291021MI <br /> EHD 29-01 1115/07 WELL PERMIT APP <br />