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v .e. <br /> San Joaquin County 1Cevironma7 <br /> al Hoatt�hpp <br /> �Departmont Unit IV Well PwTnit Alication Supplement <br /> JOB ADDRESS; ® VU 3b <br /> PERMIT SR#: <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> I hereby affirm that 1 am licensed under the provisions of Chapter 9 (commencing with Section 7000) of Division <br /> 3 of the Business and ProfessionsCode and my license is in full force and effect. <br /> License 57,4P 7-7 —Expiration Date: / Q J L <br /> Date: Contractor- �Gz-n� 6,A7 �j fit <br /> ��DI e — <br /> Signature: Title: -' La_14 <br /> Printed name; <br /> WORKERS' COMPE=NSATION DECLARATION <br /> ( 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 provided for <br /> by Section 3700 of the Labor Code, for the performance of the work for which this permit is issued <br /> e <br /> �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 /> carrier and policy numbers are; <br /> Carrier: 2 Policy Number: <br /> I certify that In the performance of the work for which this permit is issued, I shall not employ any person it <br /> any manner so as to become subject to the workers'compensation laws of Callfomia, and agree that if i <br /> should become subjecl to the workers'compensation provisions of Section 3700 of the Labor Code, I shall <br /> forthwith comply with those provisions. <br /> Date:---1� Signature: <br /> Printed Name: _ l a-+'y rj(J, <br /> WARNING.FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE 13 UNLAWFUL,AND SHALL SUBJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> (6100,000.),IN AUDITION TO TME COST OF COMPENSATION,INTEREST, ATTORNEY'S FEES,AND DAMAGES A3 <br /> PROVIDED FOR IN SECTION 3708 OF THE LABOR CODE. <br /> AUTHORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> I.—a (signature o4C-57 licensed authorized representative), <br /> hereby authorize (print name) <br /> to sign this San Joaquin County Well Permit Application on my behalf. I understand this authorization is valid for <br /> one(1)your and Is limited to the work plan dated on the front page of this appllCztlon. <br /> 8-26-021 MI — — — —— -- <br />