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San Joaquin County Environmental Health Department Unit IV Well Permit Application Supplemental <br /> JOB ADDRESS : 53 S UO _C-'I((A , h-f_Zd._ _ 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 <br /> Division 3 of the Business and Professions Code and my license is in full force and effect. <br /> License Exp Date: 15 - 31 <br /> Date: $ - Z W &I Contractor: C&4 <br /> Signature : Title : l�i¢OlL'cT yflAMKerG <br /> Print Name : <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: policy Number: <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 : S - 3 ! - // Signature: <br /> Print Name. ZOW <br /> WARNING : FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL SUBJECT AN EMPLOYER TO <br /> CRIMINAL PENALTIES AND CIVIL FINES UP TO $10030000 IN ADDITION TO THE COST OF COMPENSATION, INTEREST, <br /> ATTORNEY'S FEES, AND DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE . <br /> AUTHORIZATION FOR 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 /> arzsmzrMl <br /> EHE 19.01 1115107 WELL PERMIT APP <br />