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�� IQ rr nJ6 <br /> ra�z�A <br /> San Joaquin C myyEnnvironnmmental Health De artment Unit IV Well Permit Application Supplemental <br /> JOB ADDRESS: -, 2Z PERMIT SR# © l <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#: 611)57') 7 4 C 5-7 Exp Date: I U L,�<)` 10 <br /> Date: S;,Z2 09 Contractor: <br /> Signature: /--� // Title: <br /> Print Name: t (v+�- '•!l e,� w <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 /> C/ 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 /> Carrier_ ��2 tau.�'� (� Policy Number: W CRC Q S?D 1 sail <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, II shall forthwith comply with those provision"s..] <br /> Exp. Date: t i t I� Signature• { ~ <br /> Print Name: (I t" y rroZ <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$706 OF THE LABOR CODE. <br /> _,_AUTHQRIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> 1, i ►vw TT *,C.r` „(signature of C-57 licensed authorized representative), <br /> hereby authorize(print name) 1'Z AM R p k I C-- ,to <br /> sign this San Joaquin county Well Permit Application 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 /> 9129/021MI A <br /> EHD29-01 115W <br /> WaA PERMrr APF <br />