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.. Mr .f{�ci ;.C�i.+,�(�1•, .ws.fni.�elY,.e•:/dYd'pi•F, ,�r .. ,+..r.iaM:r.;.�'1X7M.dtif>'. <br /> San Joaquin County Environmental,Health bepart msnt Unit i Well Permit Appllcatian 1.Supplemental <br /> JOB ADDRESS: (DZL F itoA)TAG F_ 1Z.g0�PERMIT SR# <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> I hereby affirm that I am licensed under the provisions of Chapter 9(commencing with Seciion 7000)of <br /> Division 3 of the Business and Professions Code and my license is in full force and effect. <br /> License#: G-� . Exp pate: A3 / /2 <br /> Date: Contractor�� i'.��i+o- �7�- . <br /> Signature: Tide: <br /> Print Name: <br /> WORKER'S COMPENSATION 09CLARATION <br /> Tltetit7j air firrrran�c erpenaitype <br /> T� ThIti9Wlrt�-tleEltlt�ig` <br /> • I <br /> I have and will maintain a certificate of consent to self�insure for workers'compensation,as <br /> provided for by section 3700 of the labor•Code,for the performanCe of the work for which this <br /> permit is issued. <br /> I have and will maintain workers'compensation Insurance,aq required by Section 3700,af the <br /> Labor Code,for the performance of the work for which this permit is issued. My workers' <br /> _._.____...:........,._. _.....:compensation..insurarace_cariier$nd PQlipy..nurrlbere are:__,_.___ <br /> Carrier:. � 'r Policy Number: <br /> I certify that in the performance of the work for which this permit is issued,i shall not employ any i <br /> person in any manner so as to become subject to the workers'compensation law of Calif4rnla.and <br /> agree that If 1 should become stibject to workers'compensation provisions of Section 3700 of the <br /> Labor Code, I shall forthwith comply with those provisions <br /> Exp,pate: Ae�2D/D_ Signature: <br /> Print Name: "e8,:10 <br /> WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS ONLAWFUL,AND SHALL SUBJECT AN EMPLOVERTO <br /> CRIMINAL PENALTIES AND CIVIL FINES UP TO$100,000,IN AotmioN To THS COST OF COMPENSATION,INTEREST, i <br /> ATTORNEY'&FEES,AND DAMAGES AS PROVIORD FOR IN SECTION 3701 OF IRE LABOR CODE. <br /> ON FOR OTHER THAN C-97 SIGNING PERMIT APPLICATION <br /> 1, -(slgnaturs of C47 licensed authorized represeritetive), <br /> hereby authorize(print name) ;to <br /> sign this son Joaquin county Well Permit'Application on my behalf. f understand this authorization is valid. <br /> for one year and is 1'imited to the work plait dated on the front page M this appllcatlon. <br /> A!?AfORlMI <br /> END 71W 1 1 VI WELL PERMIT MP <br />