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Rpr 12 01 07: 48a n - )nes , 5-� 11 p. 2 <br /> `rte �•� <br /> DSU F oi7L� � <br /> San Joaquin Coun Environmental Hei ith Services,Unit IV Well Permit Application Suppplement <br /> ,VX E �o GSA on►) o gngp l <br /> JOB ADDRESS: Nod PERMIT SR# - G <br /> t <br /> 171 <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 Professions Code and my license is in full force and effect. <br /> License#: 6U&05 <br /> p <br /> _i O�&n 5 Expiration Date: <br /> Date: "1:`[Z-o t Contractor:_ Fi.csuA <br /> Signature:_ �--�t Lel _ Title: <br /> Printed name,��'' SLJN <br /> WORKERS'COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the following declarations: (CHECK ALL THAT APPLY) <br /> I have and will maintain a certificate of consent to self-insure for workers'compensation,as provided for by <br /> 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: 2r\ <br /> Carrier: J Qvv-, ) Policy Number: J� 3 '�6y <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'compensation provisions of Section 3700 of the Labor Code,t shall <br /> forthwith comply with those provisions. <br /> Date: 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 /> PISECTION ADDITION To <br /> HE COST <br /> OF THE F COMPENSATION,OR NTEREST,ATTORNEY'S FEES,AND DAMAGES AS <br /> PROVIDED FOR <br /> (C-57 licensed authorized representative),hereby <br /> authorize ��� C,✓� t <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 /> 5-17-20001 MI <br /> T ccncaoti,co� I r:1 a TGIC17/7.T/bG1 <br />