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n Joaquin County Environmental Health DeparUnent Unit IV tlglic <br /> ell Permit Appation Suppkrn <br /> eent <br /> JOB ADDRESS: PERMIT SR#: <br /> LICENSED CONTRACTORS DECLARATION LCD <br /> I hereby affirm that I am licensed under the provisions of Chapter g(commencing with Section 7000)of Division <br /> 3 of the Business and Professions Code and my license is in fug force and effect. p, <br /> License is -7 510 Expiration Date: I ! 3I Qy <br /> Date: -I 1 1-r 10-7 Contract : C a s Cad 2 D I'I 1 V Y1�, 1 n L <br /> Signature: TIl1e: Ope l'0. yY15 M C)Y . <br /> Printedname: MYrIeS C�tt� 1�1�e.� <br /> WORKERS' COMPENSATION DECLARATION <br /> i hereby affirm under penalty of perjury one of the foltowvrg declarations: (CHECK ONE) <br /> _I have and will maintain a certificate of consent to seH-insum for workers'compensation, as provided for <br /> by Section 3700 of the Labor Code,for the performance of the work for which this perm g is issued. <br /> I have and will maintain workers'compensation insurance,as required by Section 370D 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 numbers are: <br /> Carrier. pct 0,S V-4C - N[�kl O n w Policy Number: 0`71;WS S013 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 37DO of the Labor Code, I shag <br /> forthwith comply with those provisions. { <br /> Expiration Dates' I `0& Signature: L, I <br /> Printed Name: I'YYlR-S &itil 1 � ' <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 3708 OF THE LABOR CODE. <br /> AUTHORIZATION FO THER THAN C-57 SIGNING PERMIT APPLICATION <br /> 1, yT c (signwWmolC-671icensed authorlmd neprnsentative), <br /> hereby authorize(print(print name) W I 1 1 I CL.M La At 1 e, <br /> to sign this San Joaquin County Well Permit Application on my behalf. I understand this authonzation is valid for <br /> one(1)year and Is limited to the work plan dated on Ole front page of this application. <br /> 8-29-02 1 MI J <br /> EHD y-uz-ao i <br /> 6:_cs <br />