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0 <br /> San.foaquln County Environmental Health Department Unit IV Well Permit Application Supplement <br /> JOB ADDRESS: PERMfT Slid_ <br /> LICENSED CONTRACTORS DECLARATION L1 CD) <br /> I hereby affirm that I am licensed under the pro0slons of Chapter 9(oommencing with Section 7000)of Division <br /> 3 of the Business and Professions Code and my license is in full force and effect c� <br /> License* 41$S7 CP S— Expiration Date-, <br /> Date: Z ) 1, nn ''C1omragtpr: <br /> Signature: / — `fitt / Title:t y <br /> Printed name: 1•..��l}1 ./ �j�,( tq dy—1 <br /> WORKERS'COMPENSATION DECLARAMN <br /> I hereby affirm under penalty of perjury one of the following declarations: (CNECK(NNE) <br /> _1 have and will maintain a certYrcate of consent to selt4nsure for w xkem compensation,as provided for <br /> by Section 370D of the Labor Code,for the performance of the work for which this permit IS issued. <br /> have and wNl 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'compensallon insurance <br /> carrier and policy numbers are: �z <br /> Carrier: L-�'Ct UaA K_j- Policy Number: <br /> I certify that In the performance of the vrak for which this permit is issued,l shag not employ any person in <br /> any manner sn 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 Code, I shall <br /> "hvAh comply Wdb chose provisions. <br /> I <br /> Expkaticn Dale: ulh �D Signature: / <br /> Printed Name: <br /> WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT <br /> AN EMPLOYER TO CRIMINAL MRALM AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> i K100,000.).W ADDITION 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 /> r� SL <br /> (algnamta OrtsT mcenaM aaerorlied repreaentativa), <br /> Aereby amYwrta(print tre <br /> to sign this San Joaquin County Well Permit Applicatlan on my behalf. I under3fwd this autihodzatI m Is valid for <br /> are(i)yaw and Is limited tD the work plan dated on the front page of this application. <br /> =-29.021 MI <br /> rm 294.-001 <br /> 6r2/9r <br />