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San Joaquin County Environ tal Health Department Unit IV Well PermitApplicationSupplemental <br /> JOS ADDRESS: /yPERMiT SR# y 614>/ <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 /> License#: 0n�9r�Sn�O Exp Date: <br /> �J <br /> Date: Contractor: <br /> Signature: ,�a Title: <br /> 11SSL/r�3i?M�7F/I��f1t/Y <br /> Print Name: 11 ` A& �iPrtAit[o✓r!L <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 /> _X 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 /> compensation insurance Carrier and policy numbers are: p <br /> Carrier-;/ JWC,6"6!a Policy Number. O t/Z9s <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 subject to workers' compensation provisions of Section 3700 of the <br /> Labor Code, I s <br /> h <br /> all forthwith comply with those provisions. <br /> Exp. Date: T�//f O// Signature: u/ _ <br /> PrintName: /K/L'lf.,y- � �Ad�lp✓�Tt <br /> WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT AN EMPLOYER TO <br /> CRIMINAL PENALTIES AND CIVIL FINES UP TO$100,000,IN ADDITION TO THE COST OF COMPENSATION,INTEREST, <br /> ATTORNEY'S FEES,AND DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. <br /> UTXt T iT F ' THER THAN C-57 SIGNING PERMIT APPLICATION <br /> !, • r (signature,of C-57 licensed authorized representative), <br /> hereby authorize(print name) � It u to <br /> sign this San Joaquin county Well Permit Application on my 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 /> uzgro7�MI <br /> ew aoi wsm •.0 t,::�ui=r.�� <br />