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Opt-, <br /> San Joaquin County Environmental Health Department Unit IV Well Permit Application Supplemental <br /> JOB ADDRESS: TU/ � PERMIT SR# ��� ✓y <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#: 1 (`7 Exp Date: <br /> Date: 10 --a– 0 <br /> ok Contractor:L�ooa-llx � :�)6`1` ) UL-qj <br /> Signature: QMwAnnoi _. Title: Ir/LIP.�i C�.Qi1 <br /> Print Name:O n n CI\,\. <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:s� p 2u __ Policy Number: 0C)3.0)a3i <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, i shall forthwith comply with those provisions. <br /> Exp. Date: (7 — Signature: �y'V\,0. `l %i`) <br /> Print Name:CNMCW�.A`R.Ok –7—�t)n <br /> WARNING:FAILURE TO SECURE WORKERS'COMPENSATION GE IS UNLAWFUL,AND SHALL SUBJECT AN EMPLOYER TO <br /> CRIMINAL PENALTIES AND CIVIL FINES UP TO ,000,IN ADDITION TO THE COST OF COMPENSATION,INTEREST, <br /> ATTORNEY'S FEES,AND DAMAGES ASP DED FOR IN SECTION 3706 OF THE LABOR CODE. <br /> AUTHORIZATION OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> I, (signature of C-57 licensed authorized representative), <br /> hereby authorize(print name) ,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 /> St"t02IMI <br /> EHD 29-01 1115A7 WELL PERMIT APP <br />