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pp <br /> San Joaquin County Environmental Health Departme It Unit IV Well Permit Application Supplement <br /> JOB ADDRESS:. � _ O60 8 / <br /> . <br /> T PERMIT SR# Z <br /> 6 u "_5 <br /> LICENSED CONTRACTORS DECLARATION (LCD) <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 andProfessions Code and my license is in full force and effect. <br /> License#: X / / Expiratic 1 Date: <br /> Date; Contractor: <br /> Signature: t,t`.__ _ Title: <br /> Printed name: <br /> WORKERS' COMPENSATION hN 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•irri e for workers'compensation, as provided for <br /> by Section 3700 of the Labor Code,for the performa if the work for which this permit is issued. <br /> _I have and will maintain workers'compensation- surancl , as required by Section 3700 of the Labor Code, <br /> for the performance of the work for which this permit is is:.ued. My workers'compensation insurance <br /> carder and policy numbers are: <br /> �/ <br /> Carrier:_ c l'� Policy Number: <br /> I certify that in the pe�rformanncce f the work for which this ermit is issued, I shall not employ any person in <br /> any manner so as to become4ubject to the workers'corn rensabon laws of California, and agree that if I <br /> should become subject to tVe workers'compensation pror isions of Section 3700 of the Labor Code, I shall <br /> forthwith comply with tho provisions. <br /> Expiration Date:�Signature: <br /> Printed Name: <br /> WARNING:FAILU TO SECURE WORKERS'COMPENSATION':OVERAGE IS UNLAWFUL,AND SHALL SUBJECT <br /> AN EMPLOYER T CRIMINAL PENALTIES AND CIVIL FINES UP"0 ONE HUNDRED THOUSAND DOLLARS <br /> ($100,000,),IN DITION TO THE COST OF COMPENSATION,IN- EREST,ATTORNEY'S FEES,AND DAMAGES AS <br /> PROVIDED F IN SECTION 3706 OF THE LABOR CODE. <br /> AUTHOI N FOR OT E HAN C•57 SIGNING PERMIT APPLICATION <br /> 1 (sig iature ofCd7 licensed authorized representative), <br /> hereby authorize(print name) 1�_ T y�A <br /> to sign this San Joaquin County Well Penna 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 r of this application. <br /> &28-021 MI <br /> EHD 29-02-001 <br /> 6!22!04 <br />