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San Joaquin County Environmental Health Services, Unit IV Well Permit Application Supplement <br />JOB ADDRESS: <br />PERMIT SR#: <br />LICENSED CONTRACTORS DECLARATION (LCD) <br />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 #: ;;-- % Expiration Date: <br />Date: %—%4�_e2 Contractor: / �< <br />Signature: _ Title: <br />Printed name: <br />ERS' COMPENSATION DECLARATION <br />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 />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 <br />/numbers are: <br />Carrier. ���?� %� c c, < <<�� 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 comply with those provisions. <br />Date: � t��-,,2 _ Signature: <br />Printed Name: <br />WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAW#UL, 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 />(C-57 licensed authorized representative), hereby <br />authorize <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 />5-17-20001 MI <br />