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RECEIVED <br /> San Joaquin County Environmental Health Department unit IV Well Permit Appll o lament <br /> �r� NVIRO11111 HEALTH <br /> JOSS ADDRESS: Z=ip w PERMIT SR <br /> 5 -tat) ( )Cs� � <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> I hereby affirm that I am licensed under the provisions of Chapter 9 (commencing with Section 7000)of Division <br /> 3 of the Business and Professions Cotte and my license is in full force and effects. <br /> License Expiration Date: 7 Z o 8 <br /> Date:�D j—/0--1217 Contractor: fAj2/bI6 gf- 1 <br /> Signature: L/ ' 60 Title: <br /> Printed name- �QiJ,viSi <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the following declarations: (CHECK ONE) <br /> I have and will malntain a certificate of consent to calf-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 insurance, as required by Section.3700 of the Labor Code, <br /> for the performance of the wok for which this permit is issued. any workers'compensetion insurance <br /> carrier and policy numbers are'. <br /> Carrier. Sfn L� u,u0 (�M� itis Policy Number: <br /> I certify that in the performance of the work for which this permit is issued, I shall not employ any person m <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 Coda. I sha l <br /> forthwith comply with those provisions. <br /> Expiration Date: / Dr Dl'OT 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 T4OUSAND DOLLARS <br /> ($100,000.),IN ADDITION TO THE COST OF COMPENSATION,INTEREST.ATTORNEY'S FEES,AND DAMAGES AS <br /> 1 PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. <br /> 1 AUTHORIZATION FOR OZ1dFRTIJAN 57 SIGNING PERMIT APPLICATION <br /> o4ir f S �`r ( �J�J (signature ofC37licensed authorized representative), <br /> hereby authorize(print name) <br /> to sign this San Joaquin County Well Peftnit Appiieatlon on my behalf. 1 understand thla authorizallon la valid for <br /> one(9I year and is limited to the work plan dated on the front page of this app!lcatlon. <br /> a-29-021 M1 <br /> HND 29.0.-001 <br /> 6fnO4 <br />