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San Joaquin County Environmental Health Department Unit IV Well Permit Application Supplemental <br /> JOB ADDRESS: z�CKt 0 WQ`A La f S4or-AC-1 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* Exp Date: - ��- <br /> Date: \\ -OC\ Contractor:/y��fYX�\ild�C� <br /> Signature:Q�mj ) `r1mxr Title: K�QGl1 <br /> Print Name: ,f ) \(\ m T \k)D() L_1Q - <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 /> `t\'Po III" cy N ber: <br /> Carrier: p�tYl4� �at>�1 y a01D4& o <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: Signature: NomAjaiaAA <br /> `l <br /> Print Name: e0M'%N%. <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,AND DAMAGES AS PROVIDED FOR IN SECTION 7706 OF THE LABOR CODE. <br /> AUTHORIZATION FOR - THER THAN C-57 SIGNING PERMIT APPLICATION <br /> I, _k (Y t-t-Md) F \r (signature of C-57 licensed authorized representative), <br /> hereby authoriz (print name) ,to <br /> sign this San Joaquin county Well Permit App ation on my behalf. I 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 /> 8129102/MI <br /> EHE 2MI 1115/07 <br /> WELT PERMIT APP <br />