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San Joaquin County Environmental Health Department Unit N Well Permit Application Supplemental <br /> JOB ADDRESS: ' [.t) U LC PERMIT SR# 7 7 <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# 8� e. S 31 0 <br /> Date: -rZ' a Contractor: A cvYt ►n IjaS -S4"1 , <br /> Signature: Title: Lr.LSTdean.•- <br /> Print Name: ' �L +4 ct,i <br /> WORKEWS,COMPENSATION DECLARATION <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 selMnsure 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 performance of the work for which this permit is issued. My workers' <br /> compensation insurance carrier and policy numbers are- <br /> Carrier:!Sae,LmAPolicy Number <br /> I certify that in the performance of the work for which this permit is issued, I shag 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 toworkers!compensation provisions of Section 3700 of the <br /> Labor Code, I shall forthwith comply with those pr <br /> T� <br /> Exp.Date- f 1 r� Signature.- <br /> Print Name: - <br /> WARNING:FAILURE TO SECURE WOCOMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT AN EMPLOYER TO <br /> CRIMINAL PENALTIES AND CML FINES UP To$1014000,IN ADDITION TO THE COST OF COMPENSATION,INTEREST, <br /> ATTORNErS FEES,AND DAMAGES AS PROVIDED FOR IN SECTION <br /> AUTHORIZAT ON FOR OTHER THAN C SIGNING PERMIT APPLICATION <br /> i, $ <br /> he by authorize(print name) �+ t91� rt c � ( � ,to <br /> sign this San Joaquin county Well Permit Application on my behalf. I understand this authortimflon is valid <br /> for one year and is limited to the work plan dated on the front page of Oft applicatim <br /> sr <br /> SM2"l llr-W WELL Pmmrr APP <br />