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San Joaquin Count Environmental Health Department Unit 1V Well Permit Application Supplemental <br /> JOB ADDRESS: 0o PERMIT SR # <br /> Ve a/ s� A <br /> LICENSED CONTRAI-.CTORS DECLARATION (LCD) <br /> hereby affirm that i am licensed under he 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 an effect. <br /> License#: t Exp Date: l i <br /> .-7) <br /> Date: Contractor: 1 `! r'� ri` <br /> Signature: 2 Title: C-F— o <br /> i <br /> Print Name: J P <br /> +01ORKER`S COMPENSATION DECLARATION <br /> I hereby of rrn 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 /> parmit 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. ray workers' <br /> ccmpensation insurance carrier and policy numbers are: <br /> Carrier: S-E,A-z- ,-, i Policy Number: -% <br /> 1 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 Is71' <br /> forthwith comply with those provisions. <br /> Exp. ©ate: L- 3 ' C-- Signature: <br /> Print Name: !v e <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 /> AUT RI TION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> l (signature of C-57 licensed authorized representative), <br /> hereby aut size (,rit name) (. j( 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 /> i <br /> Ri29102/rull <br /> EK)2M! 1115107 <br />