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San Joaquin County Environmental Health Department Unit IV Wet] Permit Application Supplemental <br /> JOB ADDRESS' PERMIT SR# <br /> �v , Gf� <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> ! 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# t �+ 1 R 7 Exp Date, 1 31 2_0 'a- <br /> Date. _ Contractor QIQEUSIGIJ SaMaLtAI&� tNL <br /> Signature�� � Title L OG.AT7Qr I If otff►EitFC <br /> Print Name /JS3A r SL 14W`GQX� _ <br /> WORKER'S COMPENSATION DECLARATION <br /> i <br /> hereby affirm under penalty of perjury one of the following declarations (check one) <br /> _I nave and will maintain a certificate of consent tosetf-insure for workerscompensation as <br /> provided for by section 3700 of the labor Code, for the performance of the work for which this <br /> oermii ,s issued. <br /> -,ave and will maintain workers' compensation insurance as required by Section 3700 of the <br /> Labor Codefor the performance of the work for which this permit is issued My workers <br /> compensation insurance carrier and policy numbers are <br /> FtMERILh«i ttUTERNIFTiDIVt}L <br /> Carrier:SQl 1AJIFS, Policy Number: 0-!k 342_-61112- <br /> ' I NSv tItM�` GDMJR*�� <br /> I certify that In the performance of the work for which this permit Is issued. I shall not employ any j <br /> person in any manner so as to become subject to the workers' compensation law of California and <br /> agree that .f I should become subject to workers' compensation provisions of Section 3705 of the <br /> Labor Code I Shall forthwith comply with those pro Is®ns. <br /> Exp. Date:, GZO�G_ Signature: � ` <br /> Print Name: <br /> WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT AN EMPLOYER TO <br /> CRIMINAL PENALTIES AND CIVIL FINES UP TO 8100,0¢0.IN ADDITION TO THE COST OF COMPENSATION.INTEREST <br /> ATTORNEY'S FEES,AND DAMAGES AS PROVIDED FOR IN SECTION 1706 OF THE LABOR CODE <br /> — U i l RIZATIQN FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> I, [ l ,�_ T /y�� _1 (signature of C-57 licensed aut-h`olnzed�re�,se�nt(ative), <br /> hereby authorize(print names m! rL.�._r_'Jae-S.X.�1�_.�`.K-x_J� n-�C.,�1"JZ _. . to <br /> sign this San Joaquin county Well Permit Application on my behalf. I understand this authorization is valid <br /> for one year and is limited to the work plan dated on the front page of this application. <br /> 6rrsm2rMl <br />