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San Joaquin County Environmental Health Department Unit IV Well Permit Application Supplemental <br />JOB ADDRESS: 2 /do 1/11. 14. 1 6154 PERMIT SR # 701 <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 />Signature: e/Zt <br />Print Name:.:91b lei fv) 6 455 ec:1 <br />WORKER'S 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 <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: ER SIT Policy Number: 2 Zqh <br />I certify that in the performance of the work for which this permit is issued, I shall 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 to workers compensation provisions of Section 3700 of the <br />Labor Code, I shall forthwith comply with those provisions. <br />Exp. Date: Signature: <br />Print Name: <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 />ATTORNEYS FEES, AND DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. <br />1,:zrR,2t,g10 FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br />(signature of C-57 licensed authorized representative), <br />hereby authorize (print name) 5-4 5,o vt C, so.A,--\- , 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 />8/29/02/MI <br />License #: <br />Date: <br />Exp Date: Pia/ 5i, .2-Dr <br />Contractor: Vt . 2 p kiro <br />Title: Re, kt 11/94.t <br />EHD 29-01 11/5/07 <br /> WELL PERMIT APP