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I <br /> San Joaquin County Environmental Health Department Unit IV Well Permit Application Supplement <br /> JOB ADDRESS:,350'_00 wtln Pi, PERMIT SR#: <br /> lS, GkY5�435 <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 m license is in full force and ffect. <br /> r-77 / <br /> License#: C,5-7/ Expiration Date: <br /> Date: vZ U�j on tor: <br /> �1e�i, Ee P TYi (Id ` ( 'eS-h , .c' , <br /> Signature: / Title: C 6Z,�Tf0�\J <br /> n <br /> Printedname: C��ISTU �ef �Y (kilo-F <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 for <br /> by Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. <br /> I have and will maintain workers' compensation insurance, as required by Section 3700 of the Labor Code, <br /> for the performance of the work for which this permit is issued. My workers'compensation insurance <br /> carrier and policy numbers are: �/ <br /> Carrier: SF <br /> <br /> I certify that in the performance of the work for which this permit is issued, 1 shall not employ any person in <br /> any manner so as to become subject to the workers'compensation laws of California, and agree that if I <br /> should become subject to the workers'compensation p vi ' ns of Se n 3700 of the Labor Code, I shall <br /> forthwith comply <br /> ' ith those rovisions. <br /> Expiration Date: (71 0 Signature: '/ r <br /> Printed Name: 1 5�; �r �( wn r <br /> WARNING: FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> ($100,000.),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 /> AU IZrO/NN FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> (signature ofC-57 licensed authorized representative), <br /> hereby authorize(print name) <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 is limited to the work plan dated on the front page of this application. <br /> 8-29-021 MI <br /> EHD 29-02-001 <br /> 6/22/04 <br />