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• <br /> San Joaquin County Environmental Health Department Unit IV Well Permit Application Supplement <br /> JOB ADDRESS: PERMIT SRX-- <br /> LICENSED <br /> RSLICENSED CONTRACTORS DECLARATIONL( Cpl <br /> r hereby affirm that I am licensed under the provisions of Chapter o(commencing with Section 7000)of Division <br /> 3 of the Business and Professions Code and my license is in full force and effect <br /> License#: S— Expiration Date: //-3//0,? <br /> Date: C}ontra r: <br /> Signature: iV - Title: <br /> Printed name: ttaA a- � (t1fix name: r <br /> WORKERS'COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the follovmg declarations: (CHECK ONE) <br /> _I have and WH maintain a certificate of consent to seMansure for workers'compensation,as provided for <br /> by Section 3700 of the labor Code,for the performance of the work for whish 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 work for which this permit Is issued, My workers'compensation insurance <br /> carrier and pp�o}}licy,,numbers are: r� <br /> Carrier: L 5 C a �1�Q_ � Policy Number: <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 so as to become subject to the workers compensation laws of California, and agree that if 1 <br /> should become subject to the workers compensation provisions of Section 3700 of the Labor Code, l shall <br /> forthwith comply with those provisions. <br /> F7rpiraticn Data: z/j/Signature: <br /> PrUMed Nine; <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 DOLLARS <br /> l {Y10o,o06.), <br /> IN ADDRION TO THE COST OF COMPENSATION,INTEREST,ATTORNEY'S FEES,AND DAMAGES As <br /> ' PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. <br /> AUTHORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> If, tilcl a (Signa mro 01"70olnsed aefhorized representative), <br /> Ihe*eby aa0arim�rkrt ? , <br /> to sign I Ns San Joaquin County Wall Pemdt Application on my behalf. 1 u d this authorization Is valid for <br /> one(f)year and Is Ikntted to the work plan dated an the front page of lids application. <br /> SZ9A2 f Ml <br /> EM 294MNI <br /> 472104 <br />