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San Joaquin County Environmental Health Department Unit IV Well Permit Application Supplemental <br /> JOB ADDRESS: L 1,JA PAt�E S� �nL�ro ) 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#: '495 1 c05� Exp Date: n <br /> I �1 <br /> Date: � <br /> Contractor: <br /> Signature: , ++ Title: <br /> Print Name: c <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 /> ,4 /Lft10 / 0ch/a0 <br /> Carrier: a D� Policy Number: �- <br /> 1 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:`91 I I I Signature: 1 <br /> Print Name:NSATIoN <br /> MPLOYER <br /> WARNING FAILURE TO SECURE CRIMINAL PENALTIES AND CIVIL FINES UP TO$100,000,IN ADDITION RAGE IS URS'COMPENLAWFUL, <br /> THE COST OF COMPENSATION ENTER ST,TO <br /> ATTORNEY'S FEES,AND1pAMAGE9 AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. <br /> UT OR , TI OR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> (signature of f 57 licensed authorized representative), <br /> hereby auth riz (print name) <br /> Y] S � _ n 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 /> 8129M21MI <br /> WELL PERMIT APP <br /> EH029-01 111:107 <br />