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San Joaquin County-Environmental Health Department Unit IV Well Permit Application Supplement <br /> JOB ADDRESS: _Z'-k�& Cavi-� PERMIT SR#: 5SD,�> A <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> I hereby affirm that l am licensed under the provisions of Chapter 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#: i 5.1 LY� Expiration Date: <br /> Date: C v Q �'� fh <br /> Signature: ATitle: �l� MS Muyiq <br /> Printed name: <br /> WORKERS' COMFFNSATION-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-lnsure 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 /> l <br /> I have and will maintain workers'compensation insurance, as required;by:Section 3700 of the Labor-Code, <br /> for the performance of the work for which this permit is issued. Ally workers'compensation insurance <br /> carrier and policy numbers are: <br /> Carrier: Se 4� Policy Number: tl`1 Q 2--(D <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: 10 Signature: <br /> Printed Name: itis � � Y­ <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 /> ($900,000.),IN ADDITION TO THE.COST OF COMPENSATION,INTEREST,ATTORNEY'S FEES,AND DAMAGES AS <br /> PROVIDED FOR IN SECTION 3706OF THE <br /> ,.Aid.. <br /> CODE. <br /> TH T10 R OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> I. (signature ofCd57 licensed authorized representative), <br /> hereby authorize(print name) <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 /> 8-28.02/MI <br /> EHD 29-02-001 <br /> 6/22/04 <br />