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-IQT5 t9 <br /> AA <br /> n <br /> �� f <br /> San Joaquin Cou Environ Health Department Unit PY Well Permit Application Supplement <br /> JOB ADDRESS: 1;0 w• 6 PERMIT SR# <br /> LICENSED CONTRACTORS DECLARATIONL( CDl <br /> 1 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#: ll `� t C` T Expiration Date: / L' <br /> Date: Cl/ Contractor <br /> Signature: _ - TiUe:C1l xL� Y, )6 YC'�1 <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 will maintain a certificate of consent to self-Insure for workefs'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: Policy Number. l D -7 L 1 <br /> I certify that in the performance of the work for which this pemwt is issued, I shall not employ any person in <br /> arty 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 provisions. f <br /> Expiration Date: I I Cl _Signature: L <br /> Printed Name: �'t U �j✓ "<<..� GL <br /> WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CML FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> (=100,000.14 IN ADDITION TO THE COST OF COMIP0 sATiON,INTEREST,ATTORNE`rS FEES,AND DAMAGES AS <br /> PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. <br /> AUTHORIZAT(ON FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> ( <br /> I, \ ,( (sipnatury oiC-87licensed authorized rspresentative), <br /> hereby&L di (print Harts) r X41ky, A 44:r <br /> to sign this San Joaquin County Well Permit Application on my ff. I understand this auttwrization Is valid for <br /> one(1)year and Is limited to the work pian dated on the front page of this application. <br /> 8-29421 MI <br /> EHD 29.02-001 <br /> 6(12/04 <br />