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San Joaquin County Environmental Health Department Unit W WPermit <br /> Well Application Su--ppl ement <br /> JOB ADDRESS: PERMIT SR#: <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> I hereby affirm that I am licensed under the provisions of Chapter 9(commencing with Section 7000)of Division <br /> 13 of the Business and Professions Code and my license is in full force and effect. <br /> License#: lD 5- L�Dr7 Expiration Date (0 <br /> Date I Z' I Cc;- Contractor. <br /> Signature: Title: C, <br /> Printed name: (( V ( it <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the following declarations (CHECK ONE) <br /> _t have and will maintain a certificate 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 which this permit is issued. <br /> I have and will maintain workers' compensation insurance. as required by Section 3700 of the Labor Code, I!I <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: "tea VoK E 0 k 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 taws 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 /> forthwith comply with those provisions. <br /> i <br /> Expiration Date: t I <br /> j <br /> //', <br /> I Printed Name: i.L- rk--I ; <br /> WARNING: FAILURE TO SECURE WORKERS'COMPENSATION OVERAGE IS UNLAWFUL,AND SHALL SUBJECT I <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> ($100,000.),IN ADDITION TO THE COST OF COMPENSATION,INTEREST.ATTORNEY'S FEES,AND DAMAGES AS <br /> I PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. <br /> I AUTHORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> I Ilya <br /> '" �-' is' nature oiCS7licensed au rued representative), <br /> {. <br /> I hereby authorize(print name) <br /> I <br /> to sign this San Joaquin County Well Permit Application on my behalf, i understand s authorization is valid for <br /> i <br /> one(1)year and is limited to the work plan dated on the front page of this application. <br /> !.. <br /> 8-29-02/ Mi <br /> I[HD 19-02-Ubi <br /> 6 2)(14 <br />