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Count Environmental Health Services,Unit IV Well Permit Application Supplement San Joaquin Y PERMIT SR#: JOB ADDRESS: LICENSED CONTRACTORS DECLARATION (LCD) I hereby affirm t t I a llicens odesunder the Code andrmy lions of shn Pulelrforce and effect. (commencing with section 7000)of Division 3 of the Business Expiration Date: License#: Contractor: Date: Title: Signature: Printed name: WORKERS' COMPENSATION DECLARATION I hereby affirm under penalty of perjury one of the following declarations: (CHECK ALL THAT APPLY) nsent to Section d will maintain a Code, for the performance of co of the work for-insure for kwhichthi compensation,permit s ssupedvided for by he of _I have and will maintain workers' compensation insurance, as required workerSection 3700 o the nsuabo a Code, , for the performance of the work for which this permit is issued. My carrier and policy numbers are: Policy Number: Carrier: _I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to become subject to the workers' compensation laws of California, and agree that if I should become subject to the workers' compensation provisions of Section 3700 of the Labor Code, I shall forthwith comply with those provisions. Date: Signature: Printed Name: ON GE IS UNLAWFUL,AND SHALL AWARNING: FAILURE TO SECURE WORKERS,N EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARSSUBJECT HOUSANDOLLARSUBJECT DDITION TO THE COST OF COMP SATION, INTEREST, ATTORNEY'S FEES,AND DAMAGES AS PROVIDED ORIN SECTION 3706 OF T (C-57 licensed authorized representative), hereby authorize to sign this San Joaquin County Well Permit Application on my behalf. I understand this authorization is valid for one(t)year and is limited to the work plan dated on the front page of this application. 5-17-2000 1 MI