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San Joaquin County Environmental Health Department Unit IV Well Permit Application SupplemeM <br /> JOB ADDRESS- PERMIT SR#_ <br /> LICENSED CONTRACTORS DECLARATION ( CD) <br /> 1 hereby affirm that I am licensee under the provisions of Chapter S(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#: Expirationbate: <br /> Date: � r Contra r �Y-�..�e� F✓`7'j�� )_�L9i _._.. <br /> Signature: Titte: .�tt�(1..�� 6�-(i� <br /> I PrYttEd name: <br /> WORKERS'COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjuty vne of the follovAV declarations: (CHECK ONE) <br /> _1 harve and Witl maintain a Certificate of consent to seMansure for workers'compensation,as provided for <br /> by Section 3701 of the tabor Code,for the performance of the work for vmioh 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 policy numbers are: <br /> Carrier a hi'lit Kj`— Policy Number: <br /> 1 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, I shall <br /> fortMvRh comply v*h those provisions. <br /> Expiration Date: P&Signature: / <br /> Parted Name: <br /> WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL rNES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> (ti00,twa.),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 /> 1, / .�� (signature OIC-87 licensed oaf ml=d represeMnWe), <br /> Ehereby authorize(prart <br /> i <br /> to sign this San Joaquin county Well Period(Appltcatlon on my behalf. i u d els authorization Is valid for <br /> one(1)year and Is Pia ted to the Work pWr dared on the front page of nth application. <br /> 8,29-021 M1 <br /> PLAID L04MWt <br /> s=M4 <br />