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---------- <br /> San Joaquin County Environmental Health Department Unit IV Well Permit Application Supplemental <br /> JOB ADDRESS: PERMIT SIR 0 <br /> su 4cf�_ 44-b, <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> I hereby affirm that I am licensed under the provisions of Chapter 9(commencing with Section 7000) of <br /> Division 3 of the Business and professions Code and my license is in full force and effect <br /> License 9 !oo L, 3 9 7 ____ Exp Date I/.3112-olo <br /> Date Lo r, I U-1-11 — Contractor eAfFiI 5;AMALi,&267 IAX <br /> Signature Title _L.,0CA-T7vAJ H"A�6>L-K <br /> Print NameI��A)L <br /> WORKER'S COMPENSATION DECLARATION <br /> I 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 <br /> provided for by section 3700 of the labor Code for the performance of the work for which this <br /> permit is issued <br /> I have and will maintain workers' compensation insurance as required by Section 3700 of the <br /> Labor COCIE, for the performance of the work for which this Permit is Issued My workers' <br /> Compensation insurance carrier and policy numbers are <br /> AMFPLI4A,-J <br /> Carrier: Sie LLAAJEFK, Policy Number: JA .J � 112- (C41) <br /> I certify that in the performance of the work for which this permit is issued I shall not employ any <br /> person in any manner so as to become subject to the workers'compensation law of California and <br /> agree that if I should become subject to workers' compensation provisions of Section 3700 of the <br /> Labor Code I shall forthwith comply with those provisions <br /> Exp. Date: Signature: <br /> Print Name: <br /> WARNING,FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL.AND SHALE.SUBJECT AN EMPLOYER TO <br /> CRIMINAL PENALTIES AND CIVIL FINES UP TO$100,000.IN ADDITION TO THE COST OF COMPENSATION INTEREST <br /> ATTORNEY'S FEES AND DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE <br /> U f IT <br /> PJZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> isignature of C-57 Illcenst'I" JU)ihorized esentatwe), <br /> hereby authorize (print name) unne"(7i �-ky\Llcrs <br /> sign this San Joaquin county Well Permit Application on my behalf I understand this authoridtion is valid <br /> for one year and is limited to the work plan dated Dn the front page of this application. <br />