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8r,02- — &A/Z 7- "�� " 11'9V e � <br /> 4ua- s ssiel ,.., 1?63-7 s.Q<•�k <br /> f7sall laaJ21c - Z� �2ts�Lfye <br /> San Joaquin County Environmental Health Departme tt Unit IV Well Permit Application Sr- <br /> 0 <br /> JOB ADDRESS: 060 <br /> _ PERMIT SR#. <br /> 6�LICENSED CONTRACTORS DECLARATION L( CDi �3� <br /> I hereby affirm that I am licensed under the provisions of Ch; pter 9(commencing with Section 7000)of Division <br /> 3 of the Business andel Professions Code and my license is in full force and effect. <br /> License# X ( � / / Expiratic i Date: <br /> Date: // Contractor. <br /> Signature: A f _Title: <br /> Printed name: <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the following d,:clarations: (CHECK ONE) <br /> _I have and will maintain a certificate of consent to self-i • re for workers'compensation, as provided for <br /> by Section 3700 of the Labor Code, for the performa e,if the work for which this permit is issued. <br /> _I have and will maintain workers'compensatio nsuranc(, as required by Section 3700 of the Labor Code, <br /> for the performance of the work for w ich t permit is is! ued. My workers'compensation insurance <br /> carrier and policy numbers are: L <br /> Carrier: U Policy Number: <br /> I certify that in the performan f the work for which this )ermit is issued, I shall not employ any person in <br /> any manner so as to becom subject to the workers'coml sensation laws of California, and agree that if I <br /> should become subject to a workers'compensation pro,isions of Section 3700 of the Labor Code, I shall <br /> forthwith comply with tho a provisions. <br /> Expiration Date: Signature: <br /> Printed Name: <br /> WARNING:FAILURE TO SECURE WORKERS'COMPENSATION':OVERAGE IS UNLAWFUL,AND SHALL SUBJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP"0 ONE HUNDRED THOUSAND DOLLARS <br /> ($100,000.),IN ADDITION TO THE COST OF COMPENSATION,IN',EREST,ATTORNEY'S FEES,AND DAMAGES AS <br /> PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. <br /> AUTHO ION FOR OTE HAN C-57 iIGNING PERMIT APPLICATION <br /> (sig nature ofC-57 licensed authorized representative), <br /> hereby authorize(print name) ,.��.� ; Iy2jLt <br /> to sign this San Joaquin County Well Penult Application on my b� half. I understand this authorization Is valid for <br /> one(1)year and Is limited to the work plan dated on the front pag)of this application. <br /> B-29-02 f MI <br /> EHD 2402-001 <br /> 6(22!04 <br />