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San Joaquin County Environmental Health Department Unit IV Well Permit Application Supplemental <br /> JOB ADDRESS: L 151 Au¢y ;T-,0(-"rJ 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 <br /> Division 3 of the Business and Professions Code and my license is in full force and effect. <br /> License#: 14955 1 co S— Exp Date: 1/,�sI � l d <br /> Date: Contractor: � rC(�c, /XVII I✓lgl <br /> Signature: ,' l`'u. 1t v_II Title: _ <br /> Print Name: Lof-,ti <br /> WORKER'S 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 <br /> provided for by section 3700 of the labor Code, for the performance of the work for which this <br /> permit is issued. <br /> I have and will maintain workers' compensation insurance, as required by Section 3700 of the <br /> Labor Code, for the performance of the work for which this permit is issued. My workers' <br /> compensation insurance carrier and policy numbers are: <br /> Carrier: A Dry Policy Number: A �G�c10 � OL///00 <br /> I certify that in the performance of the work for which this permit is issued, I shall not employ any <br /> person in any manner so as to become subject to the workers' compensation law of California, and <br /> agree that if I should become subject to workers' compensation provisions of Section 3700 of the <br /> Labor Code, I shall forthwith comply with those provisions. / <br /> Exp. Date: �tl U / �- Signature: LlL <br /> Print Name: �N/1 <br /> WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT AN EMPLOYER TO <br /> CRIMINAL PENALTIES AND CIVIL FINES UP TO$100,000,IN ADDITION TO THE COST OF COMPENSATION,INTEREST, <br /> ATTORNEY'S FEES,ANDIDAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. <br /> LIT ORI TI -OR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> I, (signature of C-57 licensed authorized representative), <br /> hereby authriz (print name) -- — ,to <br /> sign this San oaquin county Well Permit Application on my behalf. understand this authorization is valid <br /> for one year and is limited to the work plan dated on the front page of this application. <br /> 81291WIMI <br /> EH02401 11MV7 WELLPERMIT APP <br />