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San Joaquin County Environment H,ealt_hDepartment Unit IV Well Permit Applicati `n Supplemental <br /> �� C <br /> JOB.ADDRESS: 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 /> - 2 <br /> License#: [��LJ�l )� Exp Date: �O <br /> Date: 2 ' 2(� Contractor: I� W�1 <br /> Signature-- Title: -- <br /> ------------ <br /> Print Name: 1/ <br /> I' WORKER'S COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the following declarations: (check one) <br />�I 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 I have and:will maintain workers' compensation insurance, as required by Section 3700 of the. <br /> t Labor Code, for the performance of the work for which this permit is issued, My workers' <br /> compensation insurance carrier <br /> and policy numbers are.: <br /> Carrier: V 1�� y Policy Nurnber: 0 1 J <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 /> o workers' compensation agree that if I should.become subject t ensationrovisions of Section 3700 of the <br /> provisions <br /> Labor Code, I shall forthwith comply with those provisions. <br /> Exp. Date <br /> t Signature:.. <br /> Print Name: <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 3706 OF THE LABOR CODE. <br /> !�,UR —TH.R—THAN C-57 SIGNING.PERMIT APPLICATION <br /> - <br /> (signature of C-57 licensed authorized representative), <br /> hereby authorize(print name) Et�I�L 9 le l ifblrt Ow sxSMmN S t •, ,to <br /> sign this San Joaquin county Well permit Application on my behalf. t understand this authorization is valid <br /> I for one year and is limited to the work plan dated on the front page of this application. <br /> i� <br /> 6129107.IMI <br /> 5HO 29-61 1115N7 WELL PERMIT APP <br />