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Contractor: ks-z, r LL Date; <br />Signature: <br />Printed name: V ) I ,* <br />gq3 <br />San Joaquin County 'nvirorrrnantal Health Department Unit IV Well Permit Application Supplement <br />JOB ADDFRESS; 2.219411. it/1,,J9..1-110/yfi*a PERMIT SR t ? <br />LICENSED CONTRACTORS DECLARATION (LCD) <br />hereby affirm that I am licensed under the provisions of Chapter 9 (commeneing with Section 7000) of Division 3 of the Eiusiness and Professions Code and my license is in full force and effect <br />License*: Sti)c) 83t4 Expiration Date: kQi3/ <br />WORKERS' COMPEKATION DECLARATION <br />I hereby affirm under penalty of perjury one of the following declarations! (CHECK ONE) <br />I riefe, and will maintain a certificate of consent to self-insure for workers' compensation, as provided for by Section 3700 of the Labor Code, for the perforrnantle of the work for which this permit le issued. <br />r.,>4 I have and will maintain workers compensation Insurance, as required by Section 3700 of the Labor Code, fOr the performance of the work for which this permit is ;ssued. My workers' Pornpensation insurance carer and policy numbera ere; <br />carrier: ,...5'"CgAlr" Policy Number: <br />I certify that in the perforMance of the work for which this permit Is 1.;sued, I shall not employ any person in any manner so as to become subject to the workers' compensation laws of California, and agree that if I should become subject to the workers' compensation provisions of Section 3700 of the Labor Code, I shall forthwith comply with those provisions. <br />Expiration Date: a Signature: <br />Printed Na JLL2L ilg (f_ (0k. <br />WARNING; rAiLuRe TO SECURE I/I/ORKERS' cONIPENSATION COVERAGE IS UN/AWFUL, AND SHALL, SUP.JECT <br />AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS ($100,000.), IN ADDITION TO THE COST OF COMPENSATION, INTEREST, ATTORNEY'S FEES, AND DAMAGES AS PROVIDED FOR IN SECTION 270G OF THE LABOR CODE, <br />Af--._ ' <br />UTHORIZAT ON FOR OTHER ,T1-1 0-57 SIGNING PERMIT APPLICATION <br />k aLiiiii.I. --- <br /> (si9Ilatort of C7 licilned authorized representative), <br />TIC) 29-02-0ai <br />6/22,04 <br />hereby authorize (print name) Jill PM.Y2 Y) <br />to sign thiS San Joaquin County Well Permit Application on my belraAr. I unthrttarld this author-1=01cmle vol,10 for <br />000 Iti) year and is limited to the work plan clatnd on the front page of this applitatiem. <br />8-29-D2 / MI