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i <br /> San Joaquin County Environmental Health Department Unit IV Well Permit Application Supplemental <br /> i <br /> JOB ADDRESS: PERMIT SR# j <br /> I <br /> i <br /> I <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#: �I 7 Exp Date: j � I26I� <br /> Date: 7 Contractor: 6V0 9- Y-I1 fry% <br /> —� <br /> Signature: //, Title: Tfi � f�' Vlffl¢ — <br /> 1. <br /> Print Name: VI '1�� Nqay--- <br /> s <br /> WORKER'S COMPENSATION DECLARATION i <br /> I hereby affirm under penalty of perjury one of the following declarations: (check one) j <br /> 1 <br /> I have and will maintain a certificate of consent to self-insure for workers' compensation, as I <br /> provided for by section 3700 of the labor Code, for the performance of the work for which this <br /> permit is issued. I <br /> i 1 <br /> _I have 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: b� I\ <br /> Carrier: /'v1�yl� Policy Number: _/'1090,2(_O/ <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 if I should become subject to workers'compensation provisions of Section 3700 of the <br /> Labor Coude, I shall forthwith comply with those proviiSIDnn/sem/j { � <br /> Exp. Date: 8�t I� Signature: gjgiGj�l2, <br /> Print Name: �+ - <br /> WARNING: FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT AN EMPLOYER TO <br /> CRIMINAL PENALTIES AND CIVIL FINES UP TO$100,000,IN ADDITION TO THE COST OF COMPENSATION,INTEREST, <br /> ATTORNEY'S FEES,AND DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. <br /> IN AOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> L (signature of C-57 licensed authorized representative), <br /> hereby authorize(print name) Dan) Scm,>Ei,-'C-R- to <br /> sign this San Joaquin county Welt 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 /> 61291021MI <br /> I <br /> F.MSBD, 11M7 <br /> WELL PERMIT APP' <br />