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'i= - -I► • � it <br /> ­Sanoaquin aunty Environmental Health Department Unit 1V Well Permit App <br /> lication Supplemental <br /> JO ESS: • ZZSZ .�' <br /> 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 !fu(lllfforce and effect. } r, <br /> C� <br /> License Exp Date: .1.v r v <br /> Date: V Contractor: RW WD h, CU1 ` o <br /> nMLEi+- <br /> Signator <br /> Title J _ 44 <br /> L -T -.•, -,. r-sem -. . <br /> Print Name: , <br /> WORKER'S'COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the following declarations: (check one) <br />� <br /> I have and n 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 a`nd policy numbers are: <br /> " C3 <br /> Cartier: Sfaie I Po"licy Number: - <br /> I certify that in the performance of,the work for which this permit is issued, 1 shall not employ any <br /> person in any manner sous 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 /> w Labor Code, I shall forthwith comply with those provisions. <br />' Exp. Date: l� Si nature* <br /> Print Name: . L.JL <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 /> t <br /> TliER THAN C-57 SIGNING PERMIT APPLICATION <br /> (signature of C-57 licensed authorized representative), <br /> 4 hereby authorize(print name) L to <br /> sign this San Joaquin county Well Permit Applicationon-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 /> A1291021MI <br />° EFSq Z9-07 1115107 WELL PERMIT APP <br />