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red U1 Ub U4:bV p.2 <br /> San Joaquin County Environmental Health Department Unit IV Well Permit Application Supplement <br /> JOB ADDRESS: PERMIT SR#- <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> 1 hereby affirm that I am licensed under the provisions of Chapter 9(commencing with Section 70 00)of Division <br /> 3 of the Business and Professions Code and my license is In full force and effect. <br /> License#: �.Stu ������ Expiration Date: / [� <br /> Date: Con r: <br /> Signature: n� Title: <br /> Printed name: <br /> WORKERS'COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the following dedarations: (CHECK ONE) <br /> I have and will maintain a certificate cl consent to self4risure for workers'Compensation,as provided for <br /> by Section 3700 of the Labor Code,for the performance of the work forwhich this permit is issued. <br /> .ZI have and will maintain workers'compensation insurance,as required by Section 3700 of the Labor Coda, <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- �i, t- Policy Numberna�L— <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 <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 /> Dcpiration Date:5 � $ignature:_ (. <br /> Printed Name:��_� ��' <br /> WARNING:FAILURE TO SECURE WDRKERS'COMPENSATION COVERAGE IS VNLAWFUL,AND SHALL SUBJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> (6100,000.).1N 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 FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> I, (signature ofC-57 licensed authorized reprosendrthm), <br /> hermby authorize(print name) <br /> to elgn this San Joaquin County Well Permit Application on my behalf. t understand this authorisation Is valid for <br /> Lon*(1)year and Is limited m the work plan dated on the front page of this aDpllcation. <br /> 0-28-02/MI <br /> END 29-02-Mi <br /> 6/2.2bo <br /> Z0 39Vd 9NI-nIa(l 99319 ZOE0ElESZ6 lZ:Ll S00Z/l0/Z0 <br />