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San Joaquin County Environmental Health Department Unit IV Well Permit Application Supplement <br /> JOB ADDRESS: PERMIT SR#: ___ <br /> LICENSED CONTRACTORS DECLARATION LCD <br /> I hereby affirm that I am ficensed 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 a: eTd "3 3 y Expiratlon Date:_ <br /> r <br /> Date: cE Contractor. <br /> Ignatu <br /> Printed name: <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the following declarations: (CHECK ONE) <br /> _I have and WIN maintain a certificate Of Consent to self4nsure for workers'oompensabon,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 win maintain workers'compansallon Insurance,as required by Section 37DO 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: <br /> Carrier: 1-1 � Policy Number: (e C-f G- %2 <br /> 1 certify that in the performance of the work for which this permit is Issued,1 shalt 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 3700 of the Labor Code, I shall <br /> forthwith comply with those provlslons. <br /> Expiration Date: (WI/106 Signature: <br /> Printed Name: — ---• <br /> WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE 15 UNLAWFUL,AND SHALL SUBJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> PROVIDED FOR ADDITION <br /> N 706 OF THE LA80R E. <br /> IN T 7COMPENSATION, <br /> INTEREST,ATTORNEY'S FEES,AND DAMAGES AS <br /> THORIZA FOR 07,E THAN C-57 SIGNING PERMIT APPLICATION <br /> I, - <br /> ( ✓'� (signatum g(C-57 1100 d aulhorizod representallw), <br /> hereby a grhzs(print name) <br /> to sign this San Joaquin County Well Pemrlt Application on my behalf. 1 understand this authorization is vdid for <br /> one(1)year and Is limited to the work plan dated on the front Page of this apPlication. <br /> 3.29-021 MI <br /> E 13 29.02-001 <br /> 612VO4 <br /> 41 <br /> l0 39Vd 9L9@GC860Z GLSOGE86OZ ZL:LT 900Z/Z0/60 <br /> a 'd Beira-899 (DES) 2UTII1JD I9a dse :90 90 aD Jew <br />