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spy - <br /> San Joaquin County Environmental Health Department Unit IV Well Permit Application Supplement <br /> JOB ADDRESS: d_I.17e, E-. 5f PERMIT SR#:,-- = <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> I hereby affirm that I am licensed under the provisions of Chapter 9 (commencing with Sectio 7000)of Division <br /> 3 of the Business and Professions Code and my license is in full force and effect.f O / <br /> License#: L S ( -7 /Expiration Date: <br /> Date: �� Q S- Contractor: !� r—cQ (/ <br /> T -�,U/y <br /> Signature: 1Ie� Title: <br /> Printed name: � �t ��� L�t Q A, <br /> WORKERS' 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 provided for <br /> by Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. <br /> 44have and will maintain workers' compensation insurance, as required by Section 3700 of the Labor Code, <br /> 41C r the performance of the work for which this permit is issued. My workers' compensation insurance <br /> carrier and policy numbers are: p <br /> I�1 U_ rS 11 Policy Number: 700 �Lt- <br /> Carrier: Y <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 /> Expiration Date: O o 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 /> AUTHORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> (,-1-- OLA A_Q_� (signature ofC-57 licensed authorized representative), <br /> hereby authorize(print name) J O'k 1 1 G)L t- hr(c nCl f Z�- C Q-, ("ti <br /> to sign this San Joaquin County Well Permit Application on my behalf. 1 understand this authorization is valid for <br /> one(1)year and is limited to the work plan dated on the front page of this application. <br /> 8-29-02/MI <br /> EHD 29-02-001 <br /> 9/30/2003 <br />