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02/22/20` G 00: 10 FAX 4vu <ac •�-•• • <br /> San Joaquin County Environmental Health Department Unit IV Well Permit Applicat(on/Supp'l`ement <br /> 1111 , 14174 FIC1.0 Awe • PERMIT SRYf: D0 Y & O 2- <br /> JOB ADDRESS: S ra_ ts_toT�^ 4S2e _ <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 /> LlcenseAl: <br /> —37 Expiration Date: <br /> r <br /> z� o Contractor. <br /> Date: t <br /> Title: mg <br /> 8lgnature: / <br /> Print name: <br /> y( <br /> WORKERS, COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the following declarations: (CHECK ONE) <br /> 9 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 /> Cartier: t� r�^� Policy Number. 3-z0� <br /> I certify that in the performance of the work for which this permit is issued, I shall not employ any parson in <br /> any manner so as to become subject to the workers'compensatton 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 /> Expiration Date: Z�, Signatures <br /> Printed Name: /�-•�- KJ <br /> WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALLSUBJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> ($100,000.),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 /> A HORIZATION O� THERRRTHAN C-57 SIGNING PERMIT APPLICATION <br /> Lam. signature ofC-67 licensed authorized representative), <br /> hereby au orize(print name, WL <br /> el <br /> to sign this San Joaquin County Well Permit Application on my behalf. 1 understand this autherl>ation IS valid for <br /> one(1)year and Is limited to the work plan dated on the front page of this apPilcad0m <br /> 8.29-021 MI <br /> EHD 29-02.001 <br /> AMIN <br /> Z 'd 6Z1,2-899 (OEs) 2U1111 JU ISN 0190 :al 90 a2 qaj <br />