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q it � :-Cl i,: F41ry. Ci'Jr ti;' <br /> 1%ih'rr'2Rr1_ Ue: :-1'A 9_hkl i' Il%t i'. <br /> • <br /> SanJoaquin County Environmental Health D artment Unit IV Well Permit APPfication Sopplemanl <br /> JOB B ADDRES5:_s a`D/ O.U. 'e4�pERMiT SR#t_� 1c i i6 <br /> la.�- Lo' . <br /> LICENSED CONTRACTORS DECLARATION (LCLI) <br /> I hereby adfirtn tha!I am licensed wide.,thrt provisions of Chapter.;(commencing with Section 70001 of Division <br /> 3 of the SUMnnoSs a,lAlPjrofesst ris Cann and my!icons iz in full force /and Affect t'} <br /> l.Icen,eit: <br /> -1 �'" IEIIA'p'��a,onUatel: "1 V� <br /> r � <br /> Signature:_ Tale: <br /> Printedname: 0 <br /> WORKER& COMPENSATI DECLARATION <br /> I hereby pffirrn under penalty of perjury one of the followln®declarations: (CHECK ONE) <br /> (have and will maintain a carttesta of consent to self-insure for worker:' compensation, as provided for <br /> by Section 3700 of the Labor Coda, for the performance of tl're work for which thin permit Is issued. <br /> I hove and will maintain workars' compensation Insurance,as required by Section 3700 of the I rfbor Code, <br /> for the performance of the work for which this permit is issued. My workers'compensation ins uranac: <br /> Carrier an policy numb <br /> Carrier:, �� Policy Number: <br /> 1 cartify that in the performance of the work for which this permA is issued, I shell not employ any person iri <br /> any manner so ac to become aub)eat to the workers'compensation laws of California, and agree that if I <br /> should become subject to the workers'compensa ion provisiorts of Ancticn 3700 of the Labor Code, I shall <br /> forthwith comply Win those provisions. <br /> Date: ,Sig nature: p ��' '4� — <br /> Printed Name: <br /> WARNING:FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL,AAD UBJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIi AND CIVIL FINDS UP TO ONt HUNDRED THOUSAND DOLLARS <br /> (S100,000d,IN ADDITION TO TI-1E COST OF COMPENSATION,INTEREST,ATTORNEY'S PEES,AND DAMAGES AS <br /> PROVIDED FOR IN SECTION 3706 OF'THE LABOR COD(1- <br /> THORIZATIO FOR PT HER THAN C-57 SIGNING PERMIT APPLICATION <br /> 7 y( ,-_, 1 _y((sIo_n,Lure ofC-s7 ficen-oa ti <br /> a pthorimcl repres entaua), <br /> harebyaulhorrnn(print name)__ V.J y�G1 ``tCK"77- <br /> to sign this San Joaquin County Wal I Prrmit Application on my behalf. I understand this auniuriratlor ie valitl for <br /> one(t)yaar and Is Ilmtted to [ho work plan datod on the front papa of thlt application. <br />