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San Joaquin County Environmental Health Department Unit IV Well Permit Application Suppiemerita} <br /> JOB ADDRESS: 7& ;0o F &wa- PERMIT SR# 456 2'1 .5 <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> I hereby affirm that I am licensed under the provisions of Chapter 9 (commencing with Section 7000)of <br /> Division 3 of the Business and Professions Code and my license is in full force and effect. <br /> #: T 6 6 Exp Date: S 31- p- /,&- <br /> License <br /> Date: 11.15'OK _ Contractor: .1631;fon") 'r,- <br /> Signature: 7 �— Title: <br /> Print Name: _ N �"1 �• (t�i��F��w�� <br /> WORKER'S 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 <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, as required by Section 3700 of the <br /> Labor Code,for the performance of the work for which this permit is issued. My workers' <br /> compensationsinsurance carrier and policy numbers are: <br /> Carrier: SWC- Policy Number: ("0C$3-2,00V <br /> I certify that in the performance of the work for which this permit is issued, I shall not employ any <br /> person in any manner so as to become subject to the workers'compensation law of California, and <br /> agree that if I should become sZWOrKk pensation provisions of Section 3700 of the <br /> La r Code,,�I shall forthwith cose provis ns. <br /> Exp. Date: v� f ture:ame:FAILURETO.SI;CUREWORKERS'COMOVERAGE IS NLAWFUL,AND SHALL SUBJECTAN EMPLOYER TO <br /> CR MINAL PENALTIES ANO CIVIL FINE00,IN AD ON TO THE COST OF COMPENSATION,INTEREST, <br /> ATTORNEY'S FEES,AND DAMAGES AR IN CTION 3708 OF THE LABOR CODE. <br /> AUTHORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> I. A (signature of C-57 licensed authorized representative), <br /> hereby 6thorize(print name) W ,to <br /> sign this San Joaquin county Well Permit Application on y behalf. I understand this authorization is valid <br /> for one year and is limited to the work plan dated on the front page of this application, <br /> 8f4WWMI <br /> EFiD 29.Ot 15t5Ni WELL PERMrr APP <br />