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i <br /> I <br /> San Joaquin County Environmental Health Department Unit IV Well Permit Application Supplement <br /> JOB ADDRESS : 10 17 Scx,+ �1 FtCSno AJQ . 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 Division <br /> 3 of the Business and Professions Code and my license is in full force and effect. (J <br /> License #: 70 �_ Expiration Date: 0�3 I /Z 0. 1 <br /> Date: 4 r Q S Contractor: C�z � <br /> Signature: �A61 \ n Title : QE \4.� <br /> Printed name : o% tA6J <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 /> � I have and will maintain workers' compensation insurance, as required by Section 3700 of the Labor Code, <br /> for the performance of the work for which this permit is issued . My workers' compensation insurance <br /> carrier and policy number's are: 7 <br /> Carrier: 54ziTe G"'7�n � �rV^ SnP�cy Number: O(D O(00q � D r <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 h se provisions. <br /> Expiration Date: r 08 Signature: a CAL X <br /> Printed Name: �n Wo. ,74 ( W <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 /> I, (signature ofC-57 licensed authorized representative), <br /> hereby authorize (print name) <br /> to sign this San Joaquin County Well Permit Application on my behalf. I 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 /> 8-29.021 MI <br /> EHD 29-02-001 Ili <br /> eiwna � <br />