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San Joaquin County Environmental Health Department Unit IV Well Permit Application Supplemental <br /> I <br /> JOB ADDRESS: 1 S e. &",m UL:f. lYA, iy.A-" PERMIT SR#. <br /> LICENSED CONTRACTORS DECLARATION LCD <br /> 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#: 41S5l(oS Exp Date: I 31 -Z-QA t> <br /> Date: 1)ELEsy18f9_ a9,aocA Contractor. C-neic��ww1 - <br /> Signature: (---K�� a ,�� Title: Vtc.-JE: <br /> Print Name: Gs-tws Cs-tp-i- r �rJ <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: RII lbc9QP DJ <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 Cotte, I shall forthwith comply with those provisions. <br /> Exp, Date: S t a pj p Signature: <br /> Print Name• �H 12i SczlJ- � <br /> WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT AN EWLOYER TO <br /> CR=NAL PENALTIES AND CIVIL FINES UP TO$100,000,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 /> AUTt-JORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> C (signature of CST licensed authorized representative), <br /> hereby authorize(print name) t,:,ts-iio,,Pthj >r t 2t�T Wti A ,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 /> stsgrozr�m <br /> EHD 29-01 111-007 WELL PERMIT APP <br />