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San Joaquin County Environmental Health Department it IV Well Permit Application Supple(hent <br /> JOB ADDRESS: 19M S. Na^+k Q�, PERMIT SR#: y <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#: C-57 (v 80 aa-7 Expiration Date: <br /> Date: 8- 1-0,003 Contractor: <br /> Signature: Title: ZP <br /> Printed name: Q Ver 1 M <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 /> I 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 policy numbers are: <br /> Carrier: S'-Ck�e�JN Policy Number: 31-1 Lf 7`1`0 O <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 provi ns of aection 3700 of the Labor Code, I shall <br /> forthwith comply with those provisions. <br /> Date: 8� I Signature: <br /> Printed Name: o Cc 0.7 <br /> WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UN WFUL,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 FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> I, (signature ofC-57 licensed authorized representative), <br /> hereby authorize(print name) . <br /> to sign this San Joaquin County Well Permit Application on my behalf. 1 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 />