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P P4- <br /> San Joaquin County Environmental Health Department Unit IV Well Permit Application Supplement <br /> JOB ADDRESS: I7- VtA tJtc-o L- 9-ACPERMIT SR#: <br /> LICENSED CONTRACTORS DECLARATIONL( CD1 <br /> 1 hereby affirm that 1 am licensed under the provisions of Chapter 9(commencing with Section 7000)of Division <br /> 3 of the Business andel Professi ns Code and my license is in full force and a e L ) <br /> Ucense#: V1,3 co, Expiration tate: Jt D <br /> Date: //__ [[ ccc�QQQQ_ 11 �,6 Y)C <br /> Signature' '"G�t� LL',{ / / Title' <br /> Printed name: �'i.F�"`I t i <br /> T' <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 workers'oompensatlon,as provided for <br /> by Section 3700 of the Labor Code,for the performance of the work for which this peril 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 <br /> Fund <br /> �am: <br /> Cartier._�/' �'r 1. J c+fol policy Number. <br /> 1 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 California,and agree that if I <br /> should became subject to the workers'compensation provisions of Section 3700 of the Labor Code,1 shall <br /> forthwlth oomply with those provisions. <br /> Expiration Date: Signature: �,tJ ! <br /> Printed Name: YL'Vl t 1 7 <br /> WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE is UNLAWF AND SHALL SUBJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CML FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> ($100,000.),IN A13MY10N TO THE COST OF COMPENSATION,INTEREST,ATTORNEY'S FEES,AND DAMAGES AS <br /> PROVIDED FOR IN SECTION 3708 OF THE LABOR CODE. <br /> AUn`T/TliORIZA`TjION 1FQR0THER THAN C-57 SIGNING PERMIT APPLICATION <br /> (signature o/C-67 licensed authonzed nrprnaenWUVe), <br /> hereby authorize(print namel <br /> to sign this Ban Joaquin County Well Perron Application on my behalf. I understand this authorization Is valid for <br /> one(1)year and Is limited to the work plan dated on the front Page of this <br /> application. <br /> 8-29-W 1 MI <br /> Ehb 29 -001 <br /> 9/302DD2 <br /> Z0 39vd DNI-1-U8a M''SA 0096696602 TZ:60 L00Z/11/01 <br />