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San Joaquin County Environmerttal Health Department Un#IV Well Permit Application Supplement <br /> JOB ADDRESS_ PERMIT SIS <br /> LICENSED CONTRACTORS DECLARATIONl( CD <br /> I hereby affirm that I am licensed under the provisions of Chapter 9(commencing with Section 7600)of Drasion <br /> 3 of the Business and Professions Code and my license is in full force and effect �7 <br /> License* �657�O S— Expiration Date:\_ //3//o 0 <br /> Date: _ Contractor: yYY-��RJ 11'j J Ili <br /> J�Signature: �� _ Title:0"Alg�b-y a`� <br /> Printed name: i►'1 .!-__ ! �� 10 ' <br /> WORKERS'COMPENSATION DECLARATION <br /> 1 hereby affirm under penalty of pedury one of the followiV declarations: +CHECK ONE) <br /> _I have and will maintain a certificate of consent to self-insure for norirers'compensation,as provided for <br /> by Section 3706 of the Labor Code,for the performance of the work for which this permit is issued. <br /> JZ!I have and will maintain workers'compensation insurance, as required by Section 3700 of the Labor Code, <br /> for the performance of the work for which this permit 13 issued My workers'compensation Insurance <br /> carrier and policy numbers are: <br /> Carrier: ' L j2 _ Policy Number: 62�1 IOT6)Z-[P( <br /> I certify that in the performance of the work for which this permit is issued,I shall not employ any person in <br /> any manner an as to become subject to the workers compensation laws or California, and agree that if I <br /> should became subject to the arorkers'compensation provisions of Section 3700 of the Labor Code, I shall <br /> fort1wAh comply with those provisions. <br /> Expiration Date: 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 THOUSAND bOLLARS <br /> ($106,006.),IN ADDITION TO THE COST OF COMPENSATION,r1TEREST,ATTORNEY'S FEES,AND DAMAGES AS <br /> PROVIDED FOR lir SECTION 3706 OF THE LABOR CODE. <br /> AUTHORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> � � �.1, Zqql <br /> /� � A (shgnamre otC.57 6ctlrsed authorized represerrtodv¢), <br /> hereby authorize"t } , <br /> to sign this Son Joaquin County Well Permit Appllcation on my behalf. 1 u d this authorization is valid for <br /> are(1)yew and Is line ted lo the work plan dried on the front page of this application. <br /> 2-2M2/MI <br /> afmzao.act <br /> 6rnm1 <br />