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Sari Joaquin County Environmental Health Department Unit IV Well Permit Application SuppfeWent <br /> .JOB ADDRESS: -t L+. i',).. PERMIT $R#. <br /> cA <br /> LICENSED CONTRACTORS DECL kATION (LCD <br /> I hereby affirm that 1 am licensed under the provisions of Chapter 9 tcornmencing with Section 7900)of Division <br /> 3 of the Business and Professions Code and my license is in full force ande <br /> License#: �? Expiration Dale, <br /> � ��r �� <br /> Date._. 2 ci <br /> Contractor. �'# " •�_ i ire'{ <br /> Li <br /> Signature: 9-114.Ill M Title-Printedname: ECkyf,,, , . <br /> WORKERS'COMPENSAT ON DECLARATION <br /> I hereby affirm under penalty of perjury one of the following declarations: (CHECK ONE) <br /> I have and Y611 maintain a Eedif;cate of consent to self-insure for workers'compensation,as provided for <br /> by Section 3700 of the Labor Code,far the performance of the work for which tills 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 wcrk for which this permit is issued. My workers'conmpensation insurance <br /> carrier and policy numbers are. <br /> Carrier. C 11 On Ah TIS Lo }!?tt r— ) -S a �1 <br /> _ 1'otic�+f�urtmlyer: € <br /> I certify that in the performance of the work for which this permit is issued,I shalt not employ any person in <br /> any manner so as to became subject to the workers'compensation laws of California,and agree that'if I <br /> should become subject to time workers'compensation provisions of Section 3700 of the Labor Code, I shall <br /> forthwith comply th those provisions. <br /> Expiration Date: L7b! &,07 Signature: <br /> Printed Name: <br /> WARNINt:FA?LUR1=TO SECURE WORKERS'COMPENSA71ON COVERAGE.IS UNLAWFUL,AND SHALL SUBJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> ($100,000)F tN ADDITION TO THE COST Or COMPENSATION,INTEREST,AYTORKEY'S FEES,AND DAli0AGE5 AS <br /> PROVIDED FOR IN SECTION 37u6 Eli~THE LABOR CODE. <br /> AUTHORIZATION FOR OTHER THAN C-57 SIGNING PERI'�iIT APPLICATION <br /> I. r1=dwiird Mrfc'tT+1.;1 �_ ; 'Pi_ fit isignattum OFC-67 licensed authorized representativel, <br /> hereby authorize(print name) `I N +L A dvr, a Gem <br /> to sign this San Joaquin County Weti PermitApptirat-son 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 /> 8-29-021 Nin <br /> EFirT z4-42-UD t <br /> lIz2J9d <br />