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_ �JOV Z@z v <br /> San Joaquin County Environment H alth Department Unit IV Well Permit Application Supplement <br /> JOB ADDRESS: o �- PERMIT SR#: <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> I hereby affirm that I am licensed under the provisions of Chz pter 9 (commencing with Section 7000) of Division <br /> 3 of the Business and Professions Code and my license is in full force and effect. <br /> License#: C J44 i', 1. J�� Expiratic i Date: ��-= - 2-U}2- <br /> Date: �- , L)�� 'C)9[ Contractor: <br /> Signature: ;.:...._ ._._ Title: �e \ OTA -_ <br /> Printed name: A `..3� <br /> WORKERS' COMPENSATI DN 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-ii isure 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 /> X I have and will maintain workers' compensation insuran :e, as required by Section 3700 of the Labor Cade, <br /> for the performance of the work for which this permit is i 3sued. My workers' compensation insurance <br /> carrier and policy numbers a��re11 /� <br /> Carrier: �))Iatt fl/� Policy Number: 01 ^100 0 —oci <br /> I certify that in the performance of the work for which th s permit is issued, I shall not employ any person in <br /> any manner so as to become subject to the workers'co npensation laws of California, and agree that if I <br /> should become subject to the workers' compensation p-ovisions of Section 3700 of the Labor Code, I shall <br /> forthwith comply with those provisions. <br /> Expiration Date: t2l I I Z1.dL�Signature <br /> Printed Name: 1 <br /> WARNING: FAILURE TO SECURE WORKERS' COMPENSATIC N COVERAGE IS UNLAWFUL,AND SHALL SUBJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES LIP 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 3705 OF THE LABOR CODE. <br /> AUTHORIZATION FOR OTHER THAN C-!i7 SIGNING PERMIT APPLICATION <br /> t`= __ ,sig�na�t�u-reofC-57 licensed authorized representative), <br /> hereby authorize(print name) � 1 ``� � ` 1 C� ��a.��ti LJ,— <br /> to sign this San Joaquin County Well Permit Application on n y behalf- 1 understand this authorization is valid for <br /> one(1)year and is limited to the work pian dated on the front page of this application. <br /> 8-29-021 MI <br /> EHD 29-024)1 <br />