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003 <br /> Sen Joaquin County Environmental Health Deipartmenx Unit IV Well Permit ApplicAtion Supplement <br /> JOB ADDRESS: PERMIT SR#: <br /> LICENSED CONTRACTORS DECLARATION LLCM <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 my license is in full force and effoct. <br /> Licensa#:(7<` -Expiration Date: <br /> Date: 0 Contractor; � fi <br /> Signature, ` <br /> Title; <br /> Printed namA; _� <br /> ------------- <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 soli-Insure for workers'compensaflon, 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 S® <br /> ctbm 3700 of the bor <br /> for the performance of the work for which this permit is issued. My workers'compensationnsu ahceCode, <br /> carrier and Policy numbers are: <br /> Carrier: I INPolley Number: <br /> In <br /> any manner so as to become subject to the workaFs'compengatlon laws of California. and agree that if <br /> should become subJact to the workers'compensation provisions of Sectibn 3700 of the Labor Code, <br /> I shall compI with those provisions. <br /> Date, <br /> Signature?�_�l� <br /> Printed IUarne; <br /> �03U <br /> • <br /> WARNING,FAILURE TO SECURE WORKERS'COMPENSATION COVERA©E IS UNLA1=11L,AND SHALL SUBJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> ($700,000•),IN ADDITION TO THE COST OF COMPENSATION, INTEREST,ATTORNEY'S FEES,AND DAMAGES AS <br /> P14OVIDED FOR IN SECTION 3706 OF THE LABOR CODE„ <br /> AUTHORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> (' • _,(signature ofC•57licensed 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 /> Me(1)year end Is Ilmitbd to the work plan dated on the flint page of this application. <br /> 8.29-021 MI <br />