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0 " <br /> San Joaquin County Environmental Health Department Unit IV Well Permit Application Supplemental <br /> JOB ADDRESS: — PERMIT SR#:::,D$-P/5y <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> I hereby affirm that I am licensed under the provisions of Chapter 9 (commencing with Section 7000) of <br /> Division 3 of the Business and Professions Code and my license is in full force and effect. <br /> License#: `1i C Exp Date: \� r 1-o <br /> Date: ContractoC: <br /> Signatura'— � Title: <br /> Print Name: <br /> WORKER'S 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 <br /> provided for by section 3700 of the labor Code, for the performance of the work for which this <br /> permit is issued. <br /> _ I have and will maintain workers' compensation insurance, as required by Section 3700 of the <br /> Labor Code,. for the performance of the work for which this permit is issued. My workers' <br /> compensation insurance carrier and policy numbers are: / <br /> Carrier: Policy Number: <br /> I certify that in the performance of the work for which this permit is issued, I shall not employ any <br /> person in any manner so as to become subject to the workers' compensation law of California, and <br /> agree that if I should become subject to workers' compensation provisions of Section 3700 of the <br /> Labor Code,. I shall forthwith comply with those provisions. <br /> Exp. Date: r j c� Signature: <br /> - <br /> /„"` Print Name: <br /> WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT AN EMPLOYER TO <br /> CRIMINAL PENALTIES AND CIVIL FINES UP TO$100,000.IN ADDITION TO THE COST OF COMPENSATION,INTEREST, <br /> ATTORNEY'S FEES,AND DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. <br /> AUTHORIZATION FOR OT ER7NAN C-57 SIGNING PERMIT APPLICATION <br /> 1. . .. ..._ i; gnature of C-57 licensed authorized representative), <br /> hereby authorize(print(name)� r� 'tcii, ��L �_ i—e- , ,to <br /> sign this San Joaquin county Well Permit Application on my behalf. I understand this authorization is valid <br /> for one year and is limited to the Work plan dated on the front page of this application. <br /> Rr2s�nvMl <br /> Ee'D 2301 11;510,' INEL PERN17 APP <br />