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• `� � -14 • <br /> San Joaquin County Environmental Health Department Unit IV Well Permit Application Supplement <br /> JOB ADDRESS: �d N•S2T- /OZ�t PERMIT SR#: W76 71" <br /> IF <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> I hereby affirm that I am licensed under the provisions of Chapter 9 (commencing with Section 7000)of Division <br /> 3 of the Business and Professions Code and my license is in full force and effect. <br /> License#: CGSI - 1-7 Cs ( Expiration Date: 1 _ 3 I - G 8 <br /> Date: 3- Z i—Q fo Contractor: GQ.JCAde, D I �� r I h (l <br /> Signature: 4/r 4 Title: OPPWA-ho hs M m yi AAfw, <br /> Printed name: YAe, T i(-TI ,✓rrfv175- <br /> WORKERS' 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 provided for <br /> by Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. <br /> I have and will maintain workers' compensation insurance, as required by Section 3700 of the Labor Code, <br /> for the performance of the work for which this permit is issued. My workers' compensation insurance <br /> carrier and policy numbers are: r ,• ' r 2 <br /> Carrier: A I (A 6L& NA (OVK 4/1 Policy Number: O5E YY ✓c30✓✓I <br /> I certify that in the performance of the work for which this permit is issued, I shall not employ any person in <br /> any manner so as to become subject to the workers' compensation laws of California, and agree that if I <br /> should become subject to the workers' compensation provisions of Section 0 of the Labor Code, I shall <br /> forthwith comply with those provisions. <br /> Expiration Date: �J' � ' 0(0 Signature: L <br /> Printed Name: ern'CG� I C-1L <br /> (f)y-ej�, <br /> WARNING: FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> ($100,000.), IN ADDITION TO THE COST OF COMPENSATION, INTEREST,ATTORNEY'S FEES,AND DAMAGES AS <br /> PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. <br /> AUTHORIZATION OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> I, (signature ofC-57 licensed authorized representative), <br /> hereby authorize(print name) �' (l <br /> to sign this San Joaquin County Well Permit Application on my behalf. I understand this authorization is valid for <br /> one(1)year and is limited to the work plan dated on the front page of this application. <br /> 8-29-02/MI <br /> ElD 29-02-001 <br /> 6/22/04 <br />