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p. 2 <br /> 14•�00 LL. .JN CROUP N$.250 002- - <br /> San Joaquin County Environmental Health Department Unit IV Well Pcrmh Application Supplement <br /> JOB ADDRESS: � PERMIT SR#:--00.39 03 <br /> 3995 <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 Lbe Business and Profe <br /> rss <br /> �ions Code and my license is in full force and effect. <br /> o <br /> 9- / 5 / f 0 ��-- Expiration Date: <br /> Date: �0 �� Cant , r_ FA;v ,, ro7-c.)C } <br /> Signature: - TRW: /ZE <br /> Prirftd name.• __ -7-t (c- <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the following dectarallons: (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 /> W the performance of the work for which this permit Is issued. My wo kers'compensation insurance <br /> carrier and policy numbers are:. <br /> Carrler:�� ,OMP. ,V 5- r-vNi�, Policy Number: �( tD l 100`7—d 3 <br /> I certify that In the performance of the work for which this permit la Issued, I shall not employ any person In <br /> any manner so as to become subject to the workers'compensation laws of Callfomia,and agree that if I <br /> should become subject to the woricera'compensation provisions of Section 37 of the Labor Code, I shall <br /> forthwith comply with those provisions. <br /> Expiration Date: 10 121 0 S Signature: <br /> X <br /> !]tinted Name: - 41 w b ( 4 <br /> WARNING:FAILURE TO SECURE WORKERS'COMPENSAT ON COVERAGE 15 UNLAWFUL,AND SHALL SUBJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNOREO THOUSAND DOLLARS <br /> (6100,000.),IN ADDITION TO THE COST OF COMPENSATION,INTEREST,ATTORNEY'S FEES,AND DAMAGES As <br /> PROVIDED FOR IN SECTION 3708 OF THE LABOR CODE. <br /> AUTHORIZATION FOR OTHERTHAN C-57 SIGNING PERMIT APPLICA71ON <br /> 1, 11 `� g✓Z {signature ofC-57 licensed authorized <br /> \ repnoaerrtattve}, <br /> hereby aumorisa(print name) G W��L a�EA2 r CT 6R ) 161 t('E 2 LL`'R <br /> to sign this San Joaquin County WeU Permit Appllcadan on my behalf. I understand this authorization Is valid for <br /> ono(1)year and Is limited to the work plan dated on the front page of this application. <br /> $-29-02/tW <br /> HHD Z9-QZ-061 <br />