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San Joaquin County Environmental Health Department Unit IV Well Permit Application Supplemental <br /> JOB ADDRESS: 140 Lathrop Road, Lathrop, C 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 <br /> Division 3 of thyez Business and Professions Code and my license is in full force and effect. <br /> License#: ,s `po Exp Date: /f,�/20/c <br /> Date: b/c Contractor: CAlP2'0 �i'dbir-j <br /> Signature: ' Title: LGfA1� <br /> Print Name: aUwiS o77 <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 /> per it is issued. <br /> I have and will maintain workers' compensation insurance, as required by 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 /> Carrier:-S'` k i-vJ CSM a T�5 Policy Number: (goo 7 3 6 3—Z e <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' c pensation law of California, and <br /> agree that if I should become subject to workers' compensati provisions of Section 3700 of the <br /> Labor Code, I shall forthwith comply with those provisions. <br /> Exp. Date: « `"ol- Zalo Signature: /� a <br /> Print Name: �iCCc/ir/ij "f% <br /> WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL 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 3700 OF THE LABOR CODE. <br /> LjT JIZION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> 6>,17 (signature of C-57 licensed authorized representative), <br /> hereby authorize(print name) /,i:./✓ de/ / i,(°/ - 'SC <br /> - ' to <br /> sign this San Joaquin county Well Permit Application on my behalf. 1 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 /> S@91021MI <br /> PHD 2401 11(:MO W t I.PFRWT APP <br />