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1 <br /> Application supplement <br /> San Joaquin County Environmental Health Department Unit IV Well Permit Appli pP <br /> JOB ADDRESS:_ O�- S <br /> � �t�oc _ PERMIT SR##. <br /> i <br /> LICENSED CONTRACTORS DECLARATION LCD l <br /> 1 hereby affirm that I am licensed under the provisions of Chapter 9(commencing with Section 7000)of Division <br /> 3 of the Business and Professions Code and my license is in full force and effect. <br /> License#: d <br /> Expiration Date: <br /> Date: Contractor. I <br /> I <br /> Signature: <br /> . Title:enoc� <br /> Printed name: <br /> WORKERS' COMPENSATION DECLARATION <br /> f <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 self-insure for workers'compensation,as provided for <br /> by Section 3700 of the Labor Code,for the performance of the work for which this permit is issued. } <br /> 121 have and will maintain workers'compensation insurance,as required by Section 3700 of the Labor Code, <br /> for the performance of the work for which this permit is issued, My workers'compensation insurance <br /> carrier and policy numbers are: <br /> Carrier:(Qr�gD 1.4.0 ,ia " ZIS —Policy Number; cWID 'R$ O 1 l <br /> certify that in the performance of the work for which this permit is issued, I shall not employ any person in <br /> any manner so as to become subject to the workers'compensation laws of California,and agree that if I <br /> should become subject to the workers'compensation provisions of Section 3700 of the Labor Code, I shall <br /> forthwith comply with those provisions. <br /> Expiration Date:117) •1-1 D Signature: f <br /> Printed Name: GAAath <br /> I <br /> WARNING: FAILURE TO SECURE WORKERS'COMPENSATIOK COVERAGE IS UNLAWFUL,AND SHALL SUBJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS I <br /> ($100,000.),IN ADDITION TO THE COST OF COMPENSATION,INTEREST,ATTORNEY'S FEES,AND DAMAGES AS <br /> PROVIDED FOR IN SECTION 3708 OF THE LABOR CODE. <br /> AUTHORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> I' (signature afC-67 licensed authorized representative), <br /> hereby authorize(print name) ISQQM_V N% <br /> r <br /> to sign this San Joaquin County Well Permit Application on my behalf. I understand this authorization Is valid for <br /> one(1)year and is limited to the work plan dated on the front page of this application. <br /> I <br /> 8-29-02 I MI <br /> i <br /> t <br /> EHD 29-02-Mi <br /> &77" i <br />