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6N37 , 4444'- 5 -%J61 A..� <br /> San Joaquin County Environmental Health Departme it Unit IV Well Permit Application Supplement <br /> Obi <br /> JOB ADDRESS:_ PERMIT SR#. o� 2 <br /> 6 u Ely_ <br /> a ml `f37 <br /> LICENSED CONTRACTORS DECLARATION L( CDi <br /> I hereby affirm that I am licensed under the provisions of Ch: pier 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 ( �?2 / Expiratic i Date: <br /> Date: Contractor <br /> Signature: �c^ 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-in-core for workers'compensation, as provided for <br /> by Section 3700 of the Labor Code,for the performapde ,f the work for which this permit is issued. <br /> _I have and will maintain workers'compensation-fnsurana , 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: D <br /> Carrier: Policy Number: <br /> I certify that in the performanf the work for which this lermit is issued, I shall not employ any person in <br /> any manner so as to becom subject to the workers'come sensation laws of California,and agree that if I <br /> should become subject to a workers'compensation prop isions of Section 3700 of the Labor Code, I shall <br /> forthwith comply with the 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"O ONE HUNDRED THOUSAND DOLLARS <br /> ($700,000.),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 THAN C-57 31GNING PERMIT APPLICATION <br /> i (sig iature ofC-57 licensed authorized representative), <br /> - <br /> hereby authodxe(print name)�1� �I r�, , S k:l i k- <br /> to sign this San Joaquin County Well Permit 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 pagr of this application. <br /> B-29-02 i MI <br /> _J <br /> EtD 2M2-001 <br /> 622!06 <br />