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San Joaquin County Environmental Health Department Unit IV Well Permit Application Supplement <br /> JOB ADDRESS_ PERMIT SRO: <br /> LICENSED CONTRACTORS DECLARATIONL( CD) <br /> I hereby affirm that I am licensed under the provisions of Chapter 9(commencing with Section 7000)of Division <br /> 3 orthe Business and Professions Code and my license is in full force and effect <br /> Ucense* �f�s�Co Expiration Data: <br /> J'I3/I0 <br /> Date: 7 CloMra r: �YZ' c3 �7'jlll-/C9i <br /> Prtrhted <br /> WORKERS'COMPENSATION DECLARATION <br /> I hereby affirm under penalty of peq'ury one of the following declarations: (CHECK ONE) <br /> _I have and will maintain a certifrcate of consent to self-insure for workers'compensation,as provided for <br /> by Section 3700 of the Labor Code,for the performance of the work for whioh this permit is issued. <br /> 1 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 Is issued, My workers'compensation insurance <br /> carrier and policy numbers are: 2 <br /> Carrier �5 a x ��Q t _ Policy Number, <br /> 1 certify that in the performance of the work for which this permit is issued.I shat not employ any person in <br /> any manner sn as to become subject to the workers compensation laws of California, and agree that it I <br /> should became subject to the workers'compensation provisions of Section 3700 of the Labor Code, I shall <br /> forthwfth comply wfth those provisions. <br /> Expiration Date: 1 j/o &Signature: <br /> Printed Nam: <br /> WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL.SUBJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FRIES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> Kt�, •t>IN ADDITION TO THE COST OF COMPENSATION,INTEREST,ATTORNEY'S FEES,AND DAMAGES AS <br /> PROVIDED FOR IN SECTION 3704 OF THE LABOR CODE. <br /> AUTHORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> (Slgnatura OIC-67 licensed mer«tsed represemaCve), <br /> hereby andwAza(praht ira�hhe - , <br /> Ito sign this San Joaquin County Well PernNt Application on my behalf. r uhdwsvmd this and horizatorh Is valid for f <br /> are(1)year and is iknitzd to the work plan dated on the hunt page of this application. <br /> 8,29-021 MI <br /> IIID29-02-001 <br /> &?7104 <br />