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San Joaquin County Environmental ealth Department Rrill IV Well Permit Application Supplemental <br /> JOB ADDRESS: �(% RMIT SR# � f <br /> 6-7 <br /> �cIF <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#: 6°)S"> 7 4 G 5-7 Exp Date: 1 6[3 y f l 0 <br /> Date: -Contractor: <br /> Signature: Title: � S <br /> Print Name: <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 /> Carrier: (L Policy Number: C 1ZCr Q S?d S 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,IIshalI forthwith comply with those provisions. <br /> Exp.Date: s t i t11O 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 COSTOF COMPENSATION,INTEREST, <br /> ATTORNEY'S FEES,AND DAMAGES AS PROVIDED FOR IN SECTION$706 OF THE LABOR CODE. <br /> _,AUTHJPR[ZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> I, ( 1 I 1 4.-- (signature of C-57 licensed authorized representative), <br /> hereby authorize(print name) tSityiVQ R©P.(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 /> s129/02/MI <br /> EHD29o, 1115m Wal PERMW APP <br />