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�68767g <br /> P. 2 <br /> San Joaquin Co <br /> untY Environmental Health Department Unit Iv <br /> well Permit Application <br /> 05 PERMIT Supplement <br /> LICENSED SRV: 33 5 <br /> I <br /> hereby CONTRACTORS DECLARATION <br /> 3 Of the Business <br /> I am licensed under the LCD <br /> ss and Professions Code and rovrsions Of C <br /> Y license ' hapten 9 (Commencing with Sect)on 700D <br /> License#: O , cl Is in full force <br /> and effect. ) of Division <br /> Date: Expirat)On Date: <br /> Contractor. 5� <br /> Signature: �C <br /> Printed name: Title: l <br /> WORKERS' COMPENSATION DECLARATION <br /> I 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 /> _ 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: <br /> CarrieC�f <br /> Carrier (1"Y'f�.r'�� =c_. " , ,(_, policy Number: <br /> C <br /> I certify that in the performance of the work for which this permit is issued, I shall not employ an <br /> y person <br /> any manner so as to become subject to the workers' compensation laws of California, and gree that if I n <br /> should become subject to the workers' compensation provisions of Section 3700 of the Labor Cade, I shall <br /> forthwith comply with those provisions. <br /> Date: `� I �f U-5 Signature: <br /> Printed Name: <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 /> (StO0,000.), 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 /> AUTHORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> (signature ofCS7licensed 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) year and is limited to the work plan dated on the front page of this application. <br /> 8-2"2/MI <br />