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W �g5 PtA, pwj,-6 yf".� <br />San Joaquin County Environmental Health Department ni <br />JOB ADDRESS:5� f r� s PERMIT SR# 5�0 <br />0 <br />I 6 <br />3 <br />e7C �v <br />LICENSED CONTRACTORS DECLARATION (LCD) <br />I hereby affirm that I am licensed under the provisions of Chapter 9 (commencing wit Section 7000) of Division <br />3 of the Business and Professions Code and my license is in full force and eff ct. <br />License #: l¢ ��(� 7 Expiration Date: 0 0 [•=�^ <br />/ . f . r <br />n�ro / l'f Con <br />Signature: <br />Printed name: <br />Title: <br />WORKERS' COMPENSATION DECLARATION <br />I hereby affirm under penalty of perjury one of 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 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 numbers are: <br />f egos-�ss� <br />Carrier: �SuPe- m. 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 />Data, 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.),DIN SECTION ON 3 E COST OF THELABORCOMP N ATION, INTEREST, ATTORNEY'S FEES, AND DAMAGES AS <br />PROVIDED FOR <br />AUTHO IZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br />�UW14 ��.� �e// S.IC (signature ofC-57 licensed authorized representative), <br />hereby authorize (print name) /> eX S/77,A OJ�'jh'+" n`F-6N <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 />