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San Joaquin County Environmental Health/Services, Unit IV Well Permit Application Supplement <br /> JOB ADDRESS: l �V PERMIT SR#: 6e2-i"06 <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> I <br /> hereby affirm that I am licensed under the provisions of Chapter 9 (commencing with secticn 7000) of Division <br /> 3 of the Business and Piofess�ons Code and my license is in full force and effect.Q <br /> License#: Expiration Date'. 3D—02 <br /> Contractor: 1( <br /> L I�ILLj/ <br /> Date: i� <br /> Si9naturo: <br /> Printed name: WA M " <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the following declarations: (CHECK ALL THAT APPLY) <br /> I have and will maintain a certificate of consent to self-insure for workers'compensation,as provided for by <br /> section 3700 of the Labor Code,for the performance of the work for which this permit is issued. <br /> 0 of <br /> e Labor <br /> I have and will tain workers!of the work for which thtion insurce, es.is permit isissued. Mylworkers'compens0aabntinsurancceGotle, <br /> for the performance <br /> carrier and policy numbers are: <br /> (,,M a4n lSSATkw�•&'Policy NumbQr. Lld� 79 i <br /> Carrier: _,,��Ar.€-]Y_� � <br /> _I certify that in the performance of the work for which this permit is issued, 1 sha11 not amploy any person in <br /> any manner so as to become subject to the workers'compensation laws of California, and agrees that if I <br /> tion provisions of section 3700 of the Labor Code. I shall <br /> should become subject to the workers' compensa <br /> forthwith Compty with those provisions. <br /> Date-- <br /> b-5-011 Signature: <br /> _ <br /> Printed Name: Wq lhaMAS� <br /> AWARIMING: FAILURE:TO SECURE N EMPLOYER TO CRIMINAL PENALTIES AND CIViLEF NESOUP TO HUNDRED THOUSAND DOLLARS <br /> GV.IS UNLAWr-UL,AND SHALL u�ECT <br /> (f1 o0,000.1,IN ADDITION TO THE DOST OF COMPENSATION,INTEREST,ATTORNEY'S FEES,AND DAIMGES AS <br /> PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, <br /> I �Llu��/r4&1� Nignitun ofC-E7 fineneed autharizsd representative), <br /> / <br /> hereby authorize(print name)_ PusTF�L 02 Z-FA &0��7' <br /> to sign this San Joaquin County Wall Permit Application on my behaff. I undmrstnnd this authorization is valid for <br /> ons(1)year and Is limited to the work plan dated on the front page of this application. <br /> 6-17-2000/Mi <br />