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Sar,. oaquin County Environmental Health D <br /> epartment Unit IV Well Permit Application Supplemental <br /> JOB ADDRESS: 5 04k PERMIT 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 <br /> Division 3 of the Business and Professions Code and my license is In full force and effect <br /> License# t, � Exp Date <br /> Date 10 Oq a0U`3 Contractor EG(SIthJ SAM0w&)& IJL <br /> Signature — Title �_OclolnQni HAUA6E1C -- <br /> Print Name GIQEh3LLA fr w4_ Fyla-D <br /> WORKER'S COMPENSATION DECLARATION <br /> hereby affirm under penalty of perjury one of the following declarations (check one) <br /> i nave and will maintain a certificate of consent to self-insure for workers' compensation, as <br /> provided for by section 3700 of the labor Code, for the performance of the work for which this <br /> permit is issued <br /> ?� , nave and will maintain workers' compensation Insurance as required by Section 3700 of the <br /> Labor Code for the performance of the work for which this permit is issued My workers' <br /> compensation Insurance carrier and policy numbers are <br /> AMEMC" IAITEQ.NFF'flGYaf}L <br /> Carrier: nI tj ers Policy Number. L Wr 3t}2 6 11 L C <br /> IHrSvra.A-w� CvM�RNM <br /> i certify that In the performance of the work for which this permit is issued, I shall not employ any <br /> person In any manner so as to become subject to the workers' compensation law of California. and <br /> agree that it I should become subject to workerscompensation provisions of Section 3700 of the <br /> Labor Code. I shall forthwith comply with those provisions p r' <br /> Exp. Date: !a13Ul LUU9 Signature: <br /> Print Name: t�4 fC D{� GVZW�L 12 C <br /> .—KNING FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT AN EMPLOYER TO <br /> CRIMINAL PENALTIES AND CIVIL FINES UP TO 5100.000.IN ADDITION TO THE COST OF COMPENSATION. INTEREST, <br /> A-,ORNEY'S FEES,AND DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE <br /> �UTk ZATIRI ON FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> _-- (signature of C-57 Ii nsed authorized represer`tat e), N <br /> i nerenyautnorize (print name) S�lAY1U SL4+)-eV tq td (]T I�Tr tAC�U-W-j�Z/fwo <br /> I sign this San Joaquin county Well Permit Application on my behalf. I understand this authorization is valid <br /> for one year and is limited to the work plan dated on the front page of this application. <br /> FJ191D71Mi <br /> �R:-reHW'4PP <br />