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Y • <br /> San Joaquin County Environmental Health Department Unit IV Well Permit Application Supplement <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 /> 3 of the Business and Professions Code and my license is in full force and effect. <br /> License#: `a O �I- 3 3�A nn Expiration Date: l 3 'S— 1 — O <br /> Date: G - I ?- U3 Contractor: R t✓ -�,UtJt2WT 5ouZc, 11L. <br /> Signature �\ wyv ( y�t,u} �� Title: V, <br /> Printed name: bo IJ U t N 9 W 1 L� <br /> WORKERS' 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 provided for <br /> by Section 3700 of the Labor Code,for the performance of the work for which this permit is issued. <br /> 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 <br /> \policy'numbers are: <br /> Carrier: W02t1�oR-& 06RA Rk f 1Ls Policy Number: 1 6(D 5 b 5 ) OD <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 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 /> Date: 9-17-03 Signature: <br /> Printed Name: Qdl� ILL(/ <br /> WARNING: FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS 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 AS <br /> PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. <br /> AUTHORIZATION <br /> FOR <br /> �OTHER <br /> �THAN C-57 SIGNING PERMIT APPLICATION <br /> (signature ofC-57 licensed authorized representative), <br /> hereby authorize(print name) <br /> to sign this San Joaquin County Well Permit Application on my behalf. I understand this authorization is valid for <br /> one(1)year and is limited to the work plan dated on the front page of this application. <br /> 8-29-02/MI <br />