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� ? <br />rc <br />i <br />San Joaquin County Environmental Ith Services U It IV Well Permit Application Supplement <br />JOB ADDRESS: ( c� . PERMIT SR#: <br />LICENSED CONTRACTORS DECLARATION (LCA) <br />I hereby affirm that I am licensed under the provisions of Chapter 8 (commencing with Section 7000) of Division <br />3 of the Business and Professions Code and my license is in full force and effect. <br />License 0, Expiration Date: <br />Date: �� �� / / Contractor: �A tw� I A'i i'�rlY -Ln C <br />Slgnatture: <br />Printed name: <br />Title: <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 consent to self -insure for workers' compensation, as provided for by <br />Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. <br />V/ I have acrd 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: Policy Number. <br />— I certify that in the performance of the work for which this permit is issued, I 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 provisions of Section 3700 of the Labor Code, I shall <br />forthwith compty with those provisions. <br />Date: <br />Signature: <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 />(=100.000.), iH ADDITION TO THE COST OF COMPENSATION, INTEREST, ATTORNEY'S FEES, AND DAMAGES AS <br />PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, <br />1, - <br />/lArn / (C-37 licensed aultwized r+epresenbdW0). hereby <br />'uti'1O�e D' k1n i4ZEnv <br />1oA) 11IIQnA) Ur� n,cxlT-►' <br />to sign this &m Jo&quin County Well Permit Application on my behalf. I understand this authorization is valid tar <br />one (1? year and Is Hmited yp the work plan dated on the front Daae of this anolication_ <br />