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t9 <br /> Sen Joaquin Cou*Envlr6­naWntaI Health Department Unit Well Permit Application Supplement <br /> // W_ !0 r SRo51g-73 <br /> JOB ADDRESS: - $o W• b PERMIT SR#� <br /> --7� CF o5iBT6 <br /> S18�� <br /> LICENSED CONTRACTORS DECLARATIONL( CD) <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#: �C [a C' l Expiration Date: <br /> Date:—Cl/ Contractor L%�1 {C�CJ �j, �ZL <br /> Signature: ti I -�- —Title:( 1 b r lriY� }� c� 1�( } � <br /> Printed name: <br /> WORKERS'COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the following declarationa: (CHECK ONE) <br /> _I have and will maintain a certtticate of consent to seN4nsure 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: <br /> Carrier: �(Z ��b CI (l Policy Number. (Z <br /> (Z 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 Caldomia,and agree that if I <br /> should become subject to the workers'cornpensation provisions of Section 3700 of the Labor Code, I shall <br /> forthwith comply with those provisions. <br /> Expiration Date: I C Signature: <br /> Printed Name: �' �L <br /> WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT <br /> AN EMPLOYER TO CRIMINAL PENALYM AND CML FINES LIP TO ONE HUNDRED THOUSAND DOLLARS <br /> ($100,000.),IN ADDITION TO THE COST OF COMPENSATION,INTEREST,ATTORNEY'S FEES,ARID DAMAGES AS <br /> PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. <br /> AUTHORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> (signatury ofC-87 Ikmnsed authorbsd representative), <br /> herby akrtlmortze(prtnt name) � Le - CA1 r cL&L5 <br /> to algn this San Joaquin County Well Permit Application on my N. I understand this authorization Is valid for <br /> one(1)year and Is limited to the work pian dated on the front page of this application. <br /> 8-294)2111111 <br /> EHD 29.02-001 <br /> 6/22/04 <br />