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San .'Gaquin County Environmental Health Department Unit IV Well Permit Application Supplemental <br />PERMIT SR # <br />LICENSED CONTRACTORS DECLARATION (LCD) <br />neleby affirm that I am licensed under the provisions of Chapter 9 (commencing with Section 7000) of <br />3;v;sion 3 of the Business and Professions Code and my license is in full force and effect <br /># Exp Date i <br />Contractor 4 51 oj <br />&gnaiure <br />Title.JUA6 <br />MAKTAIMM �Iffi= <br />WORKER'S COMPENSATION DECLARATION <br />.-,eraDy 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 />'X have and will maintain workers' compensation insurance, as required by Section 3700 of the <br />LaDor Code, for the performance of the work for which this permit is issued My workers' <br />C'r,:)mpensation insurance carrier and policy numbers are <br />Carrier: Policy Number: , (14k 3 4 2- —6 112- <br />" certify that In the performance of the work for which this permit is issued, I shall not employ any <br />person in any mariner 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 37GO of the <br />'Labor Code. I shall forthwith Comply with those pro ISlons <br />Exp. Date:_ signature: <br />Print Name: A 12 PI -J bA C-gAW-Q) P-,8 <br />WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL SUBJECT AN EMPLOYER TO <br />CRIMINAL PENAL TIES AND CIVIL FINES UP TO $100,000, IN ADDITION TO THE COST OF COMPENSATION, INTEREST, <br />A 71TORNEY*S FEES, AND DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE <br />,i ?FJ[Z TION �FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br />!A� <br />(signature of C-57 licensed authorized repntati*) <br />authorize (print name) W <br />to <br />sign this San Joaquin county Well Permit Application on my behalf. I understand this authorization is valid <br />4 <br />Oone year arid is limited to the work plan dated on the front page of this application. <br />