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--- -----------_.._ <br /> San Joaquin County Environmental Health Department Unit IV Well Permit Application Supplemental <br /> JOB ADDRESS PERMIT SR# <br /> J cp� <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> I hereby affirm that l am licensed under the provisions of Chapter 0(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# Ln3 /o '..� ' 7 Exp Date. . 1 3 1 Z.(J /oZ— <br /> Date. Contractor PkeCf51011J MI <br /> SALtti16rWLe <br /> Signature _ _a�:�-------- . ?itle Ioc&T7tJnJ MFNJA <br /> Print Name IRt2Ef-i�.. Al IJl� <br /> WORKER'S COMPENSATION DECLARATION <br /> I nereby 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 issuad <br /> I nave and will maintain workers' compensation insurance as required ay Section 3700 of the <br /> Labor Code, for the performance of the work for which this permit is issued My workers' <br /> compensation Insurance carrier and policy numbers are <br /> AMER.fc-4+J rfJTE4.nJA-t"0rJi9L <br /> Carrier. <& ,j AL OrPolicy Number: Cl} <br /> I N 5 V A-A-M.. GAM or>IJ'l <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 pro Is-r-o—n.{ss () <br /> Exp. Dater LU f Signature: <br /> Print Name: 1;9EfJD,A G*--"IV c0P-b <br /> WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT AN EMPLCYER TO <br /> CRIMINAL PENALTIES AND CIVIL FINE$UP TO$160,000,IN ADDITION TO THE COST OF COMPENSATION.INTEREST <br /> ATTORNEY'S FEES,AND DAMAGES AS PROVIDED FOR IN SECTION 3705 OF THE LABOR CODE <br /> UMQ ZAR� OR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> 5.,_-- y—�,, �) /�-, <br /> (Signature <br /> off CS7 licensed aut_h_arized�rese/ntCatge), <br /> hereby authorize(print name) ,t r!!f�. f f-i .d1.1�._tl 1_:�,.F�__ .�" i� ��.1 to <br /> sign tnfs San Joaquin county Weil Permit Application on my behalf. I understand this authorization is valid <br /> for one year and is limited to the work plan dated an the front page of this application. <br /> wxvozrMr <br />