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fie P,' <br /> San Joaquin County Environmgptal Health Department Unit IV Well Permit Application Supplement <br /> JOBADDRESS: � F6 G< GGuC PERMIT SR#: c�sS 3�S1 <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 BusinessandProfessions Code and my license is in full force and effect.sa <br /> License#: f 05q Q--7 `Expiration Date: 05 ' 31 • a()69 <br /> Date: t 1 ' C(O I,QO,�-7 Contractor: �I ) Qonen( nn <br /> Signature:_I�r t --Title: Q"fl C t' i i KAl o fi 'a <br /> Printed name: ff-Y-A rT-h <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the following declarations: (CHECK ONE) <br /> ✓1 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 Cade, <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: -GS '"�' Policy Number: 2 <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 provisions of Section 3700 of the Labor Code, I shall <br /> forthwith comply with those provisions. <br /> Expiration Date: ✓Jtiv 2 Signature: <br /> Printed Name: a IYoa-ti <br /> WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL,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 /> (signature ofC-57 licensed authorized representative), <br /> hereby authorize(print name) li/ 7-i¢ .b - plJ t/ <br /> to sign this San Joaquin County Well Permit Application on my behalf. I 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 />