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• rf � Z34 �ic,a�cs-l,GLc� <br /> San Joaquin County Environmental Health Department Unit IV Well Permit Application Supplemental <br /> JOB ADDRESS Fifth Street Well Location, Ripon, CA 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 <br /> /Business and Professions Code and my license is in full force and effect. <br /> License#: (�j 71�� Exp Date: <br /> Date: _ �L/3 0�9} r.contracto0&QA17e7- <br /> Signature: �l���'—.e' Title: <br /> WORKER'S COMPENSATION DECLARATION <br /> I <br /> I hereby affirm under penalty of perjury one of the following declarations: (check one) <br /> i <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 /> i <br /> permit is issued. <br /> E -!_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. RcCQR D Policy Number: 1(I L C 4.57©!M <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:_ I���/ - 2p /D Signature: ,,!— <br /> Print Name: -4U- 6ak h�yo-/1L,e <br /> WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT AN EMPLOYER TO <br /> CRIMINAL PENALTIES AND CIVIL FINES UP TO 5100,000,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 /> AUTHORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> 1, (signature of C-57 licensed authorized representative), <br /> hereby authorize(print name) Binayak Acharya <br /> ,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 /> i nrtsroxlMr <br /> EHp Yiat 1'.5T1 <br /> 'kFLL 4EAMiT MP <br />