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San Joaquin County Environmental Health Departinent Unit IV Well Permit Application Supplement <br /> JI OB ADDRESS: '�5OgW* 0tai ll Sf PERMIT SR#: <br /> I S-bc(Z�ll <br /> ` LICENSED CONTRACTORS DECLARATIONL{ CD) <br /> I hereby affirm that I am licensed under the provisions of Chapter 9(commencing with Section 7000)of Division <br /> 3 of the Busin—e7ss a^ndd Professions Code and my license is in full torce and effect. <br /> License•: + I' 1 51 0 Expiration Dater_ 1 3 <br /> Date: -I 1 I-7 I0-7 _Contra C4Scad4eDYit(1YlCJt , nCJ <br /> Signature: � � _ Title: OpeX0.�t UYtS (� <br /> Printedname: <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the following dedarabons: (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 utsurance,as required by Section 3700 of the Labor Code, <br /> for the performance of the work for which Rus permit is issued. My workers'compensation insurance <br /> carrier and policy numbers are: <br /> CarrierM a S k cr N wkt o tgw, Policy Number. 0-7 G WS 305 S I _ <br /> 1 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 those provisions. <br /> Expiration Date: 0& Signature: <br /> Printed Name: <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 FO THER THAN C-57 SIGNING PERMIT APPLICATION <br /> �(sslgrwlure o7C-67 fi sed authorized representauve), <br /> hereby authorize font name) w I It I QM Lt m 1 )'ems <br /> to sign this San Joaquin County Well Permit Application on my behalf. 1 understand this authvii"hoo Is valid for <br /> one(1)year and is limited to the work plan dated on the ho nt page of this application. <br /> 3-2842 I MI <br /> ERB 29-02 n m <br /> 6'2"[14 <br />