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1,' iF <br /> l, <br /> Llod <br /> 6 <br /> San Joaquin County Environmental Health Department Unit IV Well Permit Application Supplement � <br /> JOB ADDRESS: /LSD l)• JrTacl �.k coq rZ <br /> RMIT1.` SR#: <br /> LICENSED CONTRACTORS DECLARATION (LCD) <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#: $I ct `� Expiration Date: a <br /> Date: b/- 63- as' Contractor:e `c s i A4,w#7UC-4 <br /> Signatur � Title: � � �. �'db <br /> Printed na crl✓t'lt.d �(� f <br /> a <br /> WORKERS' COMPENSATION DECLARATION <br /> i, <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 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 /> CarrierPolicy Number: Z 1 W 6V K 13 J � <br /> s <br /> I certify that in the performance of the work for which this permit is issued,p 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 become subject to the workers'compensation provisions of Section 3700 of the de; I shall <br /> forthwith comply with those provisions. / <br /> Expiration Date: a y-Q/-a J Si nature• L�/![ !! <br /> P 9 <br /> 4 <br /> Printed NameK--ZiCf4A-AO <br /> WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> ($100,000.),IN ADDITION TO THE COST OF COMPENSATION,INTEREST;ATTOR,NEY'S FEES,AND DAMAGES AS <br /> PROVIDED FOR IN SECTION 3708 OF THE LABOR CODE. i <br /> �i J <br /> AUTHORIZATION FOR THAN C-57 SIGNING PERMIT APPLICATION <br /> �� u1 F <br /> I, (signature ofC-57 licensed authorized representative), <br /> V <br /> hereby authorize(print na e) i cc.+<i1--A-A 06t- I <br /> to sign this San Joaquin County Well Permit Application on my behalf. 1 understand this authorization is valid for <br /> one(1)year and is limited to the work plan dated on the front page of this application. <br /> 8-29-021 MI <br /> 1 <br /> 3 <br /> EHD 29-02-001 <br /> 6/22!04 <br /> _ � <br />