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2006-07-21 11 :57 12094683433 P 2/2 <br /> San Joa uin County Env ental H hilae Ds _ <br /> q p rtrnent unit IV Well Permit Application Suppferatent <br /> JOB ADDRESS: ' <br /> PERMIT SR#: <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> I hereby affirm that I am iicensed under the provisions of Chapter 9(commencing With Section 7000,of Division f <br /> 3 of the Business and Professions Code and my license is in full force and effect <br /> i License* Expiration Date <br /> nntractor /Clip <br /> 77 <br /> Signature: Title: <br /> Printed name: I <br /> WORKERS' COMPENSATION DECLARATION <br /> I heret)y affirm under penalty of perjury one of the following deciarations, (CHECK ONE) f <br /> I have and will maintain a certificate of consent to self-insure for workery compensation.as provided for <br /> _by Section 3700 of the Lahr Code, for the Performance of the work for which tliis permit Is issued. <br /> I �1 s i have and wii maintain workers'compensation insurance. as required by Soction 3700 of the Labor Cade <br /> for the performnee of the work for which this permit is issued. My workers ccrnpensation in <br /> carrier and policy numbers are; surancE <br /> Carrier L,5�� � � �, Ce,_WPoticY� r <br /> fltum4or. <br /> I certify that in the performance of the work for which this permit is Issued. I sany l <br /> I <br /> rson <br /> any manner so as to become subject to the workers'compensation laws of Cafifornia,and agree that if I In l <br /> should become subject to the workers•CompensaClon provisions of Section 3700 of the tabor Code. I shall j <br /> forthwith comply with those provisions. <br /> Expiration Crate:_7j&Lo Signature: <br /> Printed Name:� Sc� �nCrSC14 <br /> WARNING,FAILURE TO SECURE WORKERS'COMPENSATION COVERAGC-IS UNLAWFUL.AND SMALL SUBJECTAN j <br /> DOLLARS <br /> $100,000.0),IN ADDITION TO THE COST Of COMPENSATION,INTEREST,ATTORNEY STO CRIMIkAl.PENALTIES AND CIVIL FINE$Up To ONHUNDREDOUSAND FEES,AND DAMAGES AS <br /> PROVIDED FOR IN SEC 7"OF THE LABOR COdt_, <br /> i <br /> TI FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION � <br /> !, -- -AsigrAturo ofC•57 I(consed authorized representative), <br /> hereby authorize nt ram.) /' S r <br /> to sign this San Joaquin County Well Permit Application on my behalf. I underspnd this authorization is valid for <br /> one(f)year and is Ilinited to the work pian dated on the front page of this application, <br /> ! B-xg.U1 t MI <br />