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San Joaquin County Environmental Health Department Unit IV Well Permit Application Supplemental � <br /> JOB ADDRESS: + ; - ;?l'.� I::is 1! +i rrti:LkL� PPRMIT SR # <br /> I <br /> I <br /> 'i LICENSED CONTRACTORS DECLARATION (LCD) <br /> :iereby affirm that ! 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#: _ �, - ________ Exp Gate: ---- �o /Z <br /> Date <br /> : ` Contractor <br /> Signature- y T�" — / .--- title: �/2{ C/ CAJ /yQk)Q q-C� <br /> i Print Name: <br /> i <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 /> ipermit 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:?,x i d,, AmQ%1Cai.✓ Policy Number: -{ <br /> I <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 /> i Labor Code, I shall forthwith comply with those provisions. <br /> Exp. Date: ZO ! I Signature: <br /> Print Name: -i,-( t(S I-V C U !J <br /> WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT AN EMPLOYER TO <br /> CRIMINAL PENALTIES AND CML 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 FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> I, C 4-1 t 5 TA 7-Vy NA _ (signature of C-57 licensed authorized representative), <br /> hereby authorize(print name) , to I <br /> 1 <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 /> i <br /> PJ29R12>MI <br /> i <br /> Wt I 111W ar--;- <br />