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i <br /> i <br /> A <br /> S,a Jgaq.Uin County Environmental Health'Services Unit IV Well Permit Application Sup, <br /> Jbl 56,1 <br /> SS: 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 Dk <br /> 3 of the Business and Professions Code and my license is in full force and effect. <br /> License#: Expiration Date.- <br /> Date: <br /> ate:Date: Contractor: <br /> 1 <br /> Signature: Title: <br /> Printed name: i. <br /> i <br /> • l <br /> WORKERS' COMPENSATION DECLARATION ` <br /> t <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 1 <br /> Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. <br /> t <br /> f <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 /> i <br /> Carrier: Policy Number: <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.),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 /> I, (C-57 licensed authorized representative), hereby <br /> authorize <br /> to sin �a =_3,0 <br /> g Jg I� �uD`ty, M1/ell Permit Application on my behalf. I understand this authorization is valid for <br /> one(1)yeaaand.is4imited4o4he=work plan dated on the front page of this application. <br />