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San Joaquin County EnvirolI nm' Iental Hef'alth Department nit IV Well Permit Application Supplement <br /> JOB ADDRESS: ( Iv w� S �U S wA PERMIT SR#�: ©y*' �� 2 <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> I 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 effe . <br /> License# T � Expiration Date; <br /> Date: `� ontractor_ .y P �O 13 <br /> Signature: _ Title: <br /> Printed name: <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the following declarations: (CHECK ONE) <br /> 1 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 /> 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 are: -7 <br /> TUA� AA+ <br /> Policy Number:�'iOlI*3 736 3200 <br /> Garrier: • <br /> I certify that in the performance of the work for which this permit is issued, I 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 I <br /> should become subject to the workers' compensatio rovisions of Section 3700 of the Labor Code, 1 shall <br /> forthwith com w71/9 <br /> se provisions. J <br /> Date: '7 Signature- <br /> Printed Name: �'✓ � 1 <br /> WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> ($I o0,000.), 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 /> 4authorize <br /> RIZA ION OR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> 1' (signature ofC-57 licensed authorized representative), <br /> hprint name) <br /> to sign this San Joaquin County Well Permit Application on my behalf. I understand thls authorization is valid for <br /> one (1)year and is limited to the work plan dated on the front page of this application. <br /> 8-29-02!Ml <br />