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I San Joaquin County Environmental Health'Department Unit 1V Well Permit Applicatio <br /> (n <br /> �Suupplament <br /> JOB ADDRESS:_2Zf R N • ��` PERMIT SR#: �D ` ( sl <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> I hereby affirm that I am licensed under the provisions of Chapter 8(commencing with Section 7004)of Division i <br /> 3 of the Business and Professions Code and} my license is in full force and effect. <br /> ~ l <br /> License M — 1 V 1 5 ! 0 Expiration Date: 7.13 `1 I l <br /> Date: -` �Q Cont c r:Lf c C / f 1 ( G,I � � �� <br /> � <br /> Signature; Title: L—/, e y p s ' <br /> Printed name: V—Ye -F-- <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one o.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 cf the Labor Code,for the performance of the work for which this permit is issued. <br /> _I have and will maintain worker,'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 <br /> ,policy numbers are: <br /> Carrier: !'�L(�_ K��'" I`�dl � �� 1 Policy Number: <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 to as to become subject to the workers'compennation laws of California, and agree that if I <br /> should become subject to the workers'compensation provisions of Section 37 of the Labor Code, I shall <br /> forthwith comply with those provisions. <br /> Expiration W2M. ��.iiy�iatCirc: -�..� <br /> Printed Name- <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 /> ($104,000.),IN ADDITION TO THE COST OF COMPENSATION,INTEREST,ATTORNEY'S FEES,AND DAMAGES AS <br /> PROVIDED FOR IN SECTION 3706 OF THE LA13OR CODE. <br /> AUTHORIZATION QTNER THAN C-57 SIGNING PERMIT APPLICATION <br /> I, (slgnature afC-57 licensed authorized representative), <br /> hereby eutherize(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 pian dated on tho front page of this application. <br /> 8-2"2 f Ml <br /> EHD 29.02-001 <br /> F/9,2/Ra <br />