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I <br /> San Joaquin County Environmental Hear Department Unit IV Well Permit Application Supplemental <br /> Jog ADDRESS: 2� bv�"OERMIT SR# <br /> S IW 1Ca ql�2A0 <br /> LICENSED CONTRACTORS DECLARATION QC <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* 4_6505 65l tU 5 Exp Date: i <br /> Date: Contractor. <br /> Signatu Title: ol/t <br /> i <br /> Print Name- <br /> riS-�j�h�y'e�+VAe/' <br /> WORKER'S COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the following declarations:(check one) <br /> I <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. i <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.• S'•Po�[ V+ Policy Number: <br /> I car* that in the performance of the work for which this ploy any <br /> fy permit is issued, 1 steal!not em <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 Code, I shall forthwith comply with those provisi <br /> Exp.Date: b Signature <br /> Print Name: <br /> _ F <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 /> 42W331ehll FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> I, signature�&C-57licensed authorized representative), <br /> here�auth!®rlzerint name) ,to <br /> 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 /> ar2sara�ellr <br /> R02M ilAW WELL PMMITAPP <br />