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San Joaquin County Envirental Health Department Unit IV Well it Application Supplemental JOB ADDRESS: X)[ PERMIT SR# LICENSED CONTRACTORS DECLARATION (LCD) I hereby affirm that I am licensed under the provisions of Chapter 9 (commencing with Section 7000) of Division 3 of tthhe Business and Professions Code and my license is in full force and a ct. License#: t�0 C1 C) Exp Date: ' , i Date: F Contractor: Signature: Title: Print Name: � ', -�- , _ V1 WORKER'S COMPENSA N DECLARATION I hereby affirm under penalty of perjury one of the following declarations: (check one) I have and will maintain a certificate of consent to self-insure for workers'compensation, as provided for by section 3700 of the labor Code, for the performance of the work for which this permit is issued. I have and will maintain workers' compensation insurance, as required by Section 3700 of the Labor Cade, for the performance of the work for which this permit is issued. My workers' compensations insurance Carrie and policy numbers are: Carrier: Policy Number: I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to become subject to the workers' compensation law of California, and agree that if l should become subject to workers' compensation provisions of Section 3700 of the Labor Code,,l shall forthwith comply with those prov1S ns. i Exp. Date: 1 2..- Signature: Print Name: f`012r--r 4-- V 1 C- WARNING:FAILURE TO SECURE WORKERS,COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO$Ioo,000,IN ADDITION TO THE COST OF COMPENSATION,INTEREST, ATTORNEY'S FEES,AND DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. T O I R OTHER THAN C-57 SIGNING PERMIT APPLICATION I' signature of C-57 licensed authorized representative), hereby authorize(print name) to sign this San Joaquin county Well Permit Application on my behalf. i understand this authorization is valid for one year and is Iirnited to the work plan dated an the front page of this application. 80"2ml CND 29-01 11/5A)7 WELL PERMfT APP