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1 <br /> San Joaquin County Environmental) Health Services, Unit IV Well Permit Application Supplement <br /> JOB ADgRESS: �(o /1r•Gl/G�a�t PERMIT SR#: DMZ d 6 <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> I hereby affirm that I am licensed under the provisions of Chapter 9 (commencing with Stiction 7000)of Divlalon <br /> 3 of the Business and Professions Code and my licemio is in full force and trffoct. <br /> License#: SS lf9?c� Expir bon hate: <br /> Date: A/- /G-m Contractor: <br /> Signature: '20�e• Title: � ' rCr is c.1+/�,t�.r t�✓+-- <br /> Printed name: r_2 tio �• _ o.urta�t7 __ - <br /> WORKERS` COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the following declarations: (CHECK ALL.THAT APPLY) <br /> I have and will maintain a certificate of Gonsent to self-insure for workers' compensation, as provided for by <br /> Section 3700 of the Labor Cuda, for the performance of the work for which this puimit is issued. <br /> ✓ I havra and wlll maintain workers' compensation insurance, as required by Suction 3700 of the Labor Code, <br /> fru tt►(i p arfarmance of the work for which this permit is issued. My workore ' corn pensation insurance <br /> ceirrier anddppollcy numbers are: <br /> Cartier� /R�✓ern S _Policy Number: _� I <br /> _ I cortlfy that In tha performance of the work for which this permit is issued, I stl0ll not employ any parson in <br /> any manner so as to become subject to the workers'compensation iaawa of California, and afjrea that if t <br /> should become subject to the workers' can)pensation provisions of section 3700 oUhft-Lobor Code, I shall <br /> forthwith comply with those provisions. <br /> Date: 0/-16-d / Signature: , <br /> Printed Narne�� _,"'� lu - <br /> WARNINGFAILURE TO SECURE WORKERS' COMpt^NSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT <br /> AN EMPI_OYER'YO CRIMINAL PENALTIES AND CIVIL.FINES UP TO ONE HUNDRFO THOUSAND DOLLARS <br /> ($100,000.), IN ADDITION 1.0 THE COST OF COMPENSATION,INWREST,ATTORNEY'S FEES,AND DAMAGES AS <br /> PROVIDED FOR IN SECTION 9706 OF THE LABOR CODE. <br /> r c•I vtr4 /� »tr-�uc.t7'� ___(C.a%licensed wthorired r'epresentativa),hereby <br /> i4 G��tO <br /> authorize d�11LL ,�i�L.C----.W,�. DA- ,d✓ � _ <br /> to sign this San Joaquin County Well Permlt Application an my behalf. I undorutdnd this authorization is valid for <br /> arta(1)year and Is limited to the work plan dateci on the front page of this Application. <br /> 5-17.2000 1 Ml _.— <br />