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San Joaquin County Environmentaljiealth Dep rtrRent Unit IV Well Permit Application3/ Supplement <br />2,19 f �-e+t of 10 V) <br />JOB ADDRESS: C Z 415/ V• /t00� (o,� PERMIT SR#: — 0031,9_16 <br />LICENSED CONTRACTORS DECLARATION LCD <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 effect. <br />License #: 5_1 ��S Expiration Date: I /-?p I IOy <br />Date: IC7 DZ Contra* C -e% ovi�von C. <br />Signature: Title: O eynA <br />Printed name: C�Y 1 X71 U CJner r� Y�P.r <br />WORKERS' COMPENSATION DECLARATION <br />I hereby affirm under penalty of perjury one of the following declarations: (CHECK ONE) <br />Xhave and will maintain a certificate of consent to self -insure for workers' compensation, 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 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 r: Inumbers are: 2 Q r 1 G <br />CarrieSl ^\ Policy Number: C 1 k "J 5n2,L1) <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 comply with those provisions. <br />Date: I O/� I zd2 Signature: <br />Printed Name: C.f 1115 �1 ler- Pr �I�`-1'p�� <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.), IN ADDITION TO THE COST OF COMPENSATION, INTEREST, ATTORNEY'S FEES, AND DAMAGES AS <br />PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. <br />AUTHORIZA ION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br />I, (signature ofC-57 licensed authorized representative), <br />hereby authorize (print name) o e Au 6) 0 a At,�) (-to-' <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 plan dated on the front page of this application. <br />8-29-02 / MI <br />