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rP--i[1:EHPF'iiB 1J.JJCJE223G� _-'i'Elr'E6cct.i5 <br />(� S e.5 B/1 G523 2— <br />San <br />San Joaquin County Environmental Health Department Unit rV Well Permit Application Supplement <br />JOB ADDRESS:�O�OArf.�o�1� PERMIT SR#: D�� 3� <br />LICENSED CONTRACTORS DECLARATION (LCD) <br />I 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 #,:r �� i'O°7 Expiration Date: 0 {( I3� 42 ao <br />Date: Contractor. L ki fie o V3 <br />Signature: /r; ilei Title: LD„ niC-,,�- <br />Printed name: or,, N 'I � b <br />WORKERS' 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 self -insure for workers' compensation, as provided fcr <br />b <br />y SeIon 3700 of the Labor Code, for the performance of the worts for which this permit is issued, <br />/ nd willmaintain workers' compensation insurance, as required by Section 3700 of the Labor Code, <br />for the performance of the work for which th's permit Is Issued, My workers' ccmpensedon Insurance <br />carrier and policy numbers are: <br />Carrier: S'TArrk::. F,JNfff'�Cz;-np 1,�S Policy Number: b a —200 <br />i 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' compensetlon laws of California, and agree that if I <br />should become subject to the workers' compensation visions of Section 3700 of the Labor Code, I shall <br />forthwith comply with those provisions. <br />Expiration Date: .a `48 Signature: �. <br />Printed Name: <br />WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVi:RAGE IS UNLAWFUL, AND SHALL SUBJECT <br />AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FiNES UP TO ONE HUNDRED THOUSAND DOLLARS <br />(5100,000.), IN ADDITION TO THE COST OF COMPENSATION, INTEREST, ATTORNEY'S FEES, AND DAMAGES AS <br />PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. <br />AUTH IZAT N FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br />1, .�-v / (signature ofC-67 licensed auttlorized representative), <br />mL <br />hereby authorize (print na <br />e) L1,1 edt- <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 fs limited to the work plan dated on the front page of this appilratlon. <br />rl1D _9.01-0UI <br />