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y `UO a: 57HM HP LRSERJET 3200 , <br /> z P. 1 <br /> F <br /> in County Environmental ealth Department Unit IV Well Permit Application Supplement <br /> ESS: � (� G(/ <br /> PERMIT SR#: <br /> LICENSED CONTRACTORS DECLARATION LCD <br /> that{ am licensed under the provisions of Chapter'Q(commencing with Section 7Q{3p)of Division <br /> ss and Professions Code and my license is in full force and effect. <br /> Expiration Date: <br /> Contractor: <br /> Signature: Title: <br /> Printed name: <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the following declarations: (CHECK ONE) <br /> I hal a and will maintain a certificate of consent to self-Insure for workers'oorrrpensat!on.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 rewired by Section 3700 of the tabor 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- <br /> I <br /> I certify that in the performance of the work for which this permit is issued, I shall not 8MPloy any person in <br /> any manner so as to become subject to the workers'compensation taws of California,and agree that if I <br /> should become subject to the workers'compensation provisions of Section 3700 of the Labor Code,t shall <br /> forthwith comply with those provisions. <br /> Daae: Signaturii: <br /> Printed Name: <br /> WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE is UNLAWFUL,AND SHALL SUBJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES ANIS CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> 4109,000.),IN AbDrr N TO THE COST OF COMPENSATION,INTEREST,ATT'ORNEY'S FEES,AND DAMAGES AS <br /> PROVIDED FOR IN SECTION V06 OF THE LABOR CODE. <br /> AUTHORIZATION r~C1R 0MER THAN C-57 SIGNING PERMIT APPLICATION <br /> I' (signature ofC 67 licensed authorized re <br /> presenbithvN <br /> har by authd (print name) `–i <br /> Ito slgirthis San Joaquin Coursty Well Penidt A-0pi cation on my behalf. i understand this authorbmdon is valid for <br /> one(1)year and Is limited to the work plass dated on the frontpage of this application. <br /> 8-29421 MI <br />