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5� <br /> San Joaquin County Environmental Health Services, Unit IV Well Permit Application Supplement <br /> JOB ADDRESS : 51DJ.') I rCj� u b • flyk iv) PERMIT SR#: <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 effect. <br /> License #: lpocloq Expiration Date: �IzJ0I00 <br /> Date: - _ C Contractor: V dNl d Jilw% l If1/C� - <br /> Signature: ( l7 ''•(n� i ,:I.f—k"' ctJ Title: k` l/1pa4tuLt1� <br /> Printed name: I Lk]2124 <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 /> _v�e 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 /> Carrier: AX) �CiG�P . _ Policy Number: Nwc ,5 )J� '-Q'C) <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, I 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 /> ($100,000.)2 IN ADDITION TO THE COST OF COMPENSATION, INTEREST, ATTORNEY'S FEES, AND DAMAGES AS <br /> PROVIDED FOR IN SEC3706 OF THE LABOR CODE. <br /> 1, (C-57 licensed authorized representative), hereby <br /> authorize `n <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 /> I <br />