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San Joaquin County Environmental Health Department Unit IV Well Permit Application Supplemental <br />JOB ADDRESS: 361/ E. tuATZ-zuv AThi Stcue-Tvki PERMIT SR # <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 />License #: C6-3 - f34 0-4 `1S- Exp Date: <br />Date: Z2--ZDoi Contractor: DIvirO MfOn-CAJO <br />Signature: tAirsOre age-ed# <br />Print Name: 7,qi ORF A 10 <br />en <br />Title: 7a-e-sii)Ear Owt-iug. <br /> <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: 6-rik.r.- Policy Number: <br /> <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: t\k.p.,•( a 00 9 Signature: <br /> <br />Print Name: 44002-e-A/ 0 <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 />AUTHORIZATION FfpOTHER THAN C-57 SIGNING PERMIT APPLICATION <br />1, (signature of C-57 licensed authorized representative), <br />hereby authorize (print name) fka 6,1 LA-Of_m_ S ((Z L. %AA CO 4/Q tlwrkt4S, ,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 />R/29102 /MI <br />EHD 29-01 11/5/07 <br />WELL PERMIT APP