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NOIJ-07-2007 10%:37 TERP-l-ON - ROSEVILLE 916 784 348'-1 P.02 <br /> San Joaquin County Environmental Health Department unit IV Well Permit Application Supplement <br /> JOB ADDRESS �' �` `��"' � `A' PERMIT SR#: <br /> LICENSED CONTRACTORS DECLARATION (LPD <br /> I hereby affirm that I am licensed under the provisions of Chapter 8 (commencing with Section 7000)of Division <br /> 3 of the Business acid Professions Code and my license is in full force and effect <br /> License#: 7St43 Expiration Date. <br /> Date 1 -7 Contractor:-4Zt5-r 0c11l 1 <br /> Signature: Title:_!! - +' <br /> Printed name: <br /> WORKERS' COMPENSATION DECLARATION <br /> 1 hereby affirm under penalty of perjury one of the following declarations: (CHECK ONE) <br /> I 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, <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: � � t! w—Yd 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 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 /> Expiration Date: Signature:-:L <br /> Printed Name: �t I, ; —.— <br /> WARNING:FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE 15 UNLAWFUL, AND SHALL SUBJECT <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 A5 <br /> PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. <br /> AUTHORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> 1, <br /> (signature afC-57 licensed authorized repro®entztiveh <br /> hereby authorize(print nam <br /> �Q-Cc'c.L'D.I. .t-� <br /> to sign this Sun Joaquin County Well Permit Application on my behalf- I understand this authorization i8 valid for <br /> one(1)year and is limited to the work plan dated on the front page of this application. <br /> 8-29-021 MI _ <br /> EHD:9.02-001 <br /> 60/04 <br />