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Aug 05 2009 8: 20PM HP LASERJET FAX p. 2 <br /> San Joaquin County Environmental Health Department Unit IV Well Permit Application Supplemental <br /> JOB ADDRESS: I;Altl <br /> -H lk 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 andProfessionsCode and my license is in full force and eftct. <br /> License Exp Date: tp/so <br /> Date; � ® Contractor: <br /> Signature: a Title: l�7� -i L�in SLI26 <br /> aC) <br /> Print Na e: <br /> WORKER'S COMPENSATION DECLARATION <br /> I hereby affirm under malty 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 <br /> provided for by section 3700 of the labor Code,for the performance of the work for which this <br /> permit is issued. <br /> I have and will maintain workers' compensation insurance, as required by Section 3700 of the <br /> Labor Code, for the pe ance of the work for which this permit is issued. My workers' <br /> compensation insurance Gamer and policy numbers are: <br /> -y <br /> Carrier: �£ Y1? Policy Number. E l J -� <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 d I should become subject to workers'compensation provisions of on 3 of the <br /> Labor Code, I shall forthwith comply with those provision <br /> Date: d� k >C) L [..� Signature: <br /> Print Name- <br /> WARNING: <br /> ame•W ING:FAILURE TO SECURE KERS'C TION C E IS UNI 11NO SHALL SUBJEGT AN EMPLOYER TO <br /> CRIMINAL PENALTIES AND CIVIL FINES UP TO$100, ON ADDITION TO THE COST OF COMPENSATION,INTEREST, <br /> ATTORNErS FEES,AND DAMAGES AS RRovIDED FOR IN SECTION 3706 OF THE LABOR CODE. <br /> AUTHORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> 1, 6�"Ona tQ .T �rtN C7k--_ _ _ _ (signature of C-57 licensed authorized representative), <br /> hereby authorize(print name) jn5 r�[ to <br /> sign this San Joaquin county Well Permit Application on my behalf. 1 understand this authorization is valid <br /> for one year and Is limitedto the work plan d on the front page of this a icatlon. <br /> snsra2nal <br /> EHD 29-01 7115107 WELL PERMrr APP <br />