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W �g 5 P-)� yf;�C-1 <br />San Joaquin County Environmental Health Department Unit IV well vermn Hppll0OV�102,.1-11L <br />JOE' P DDRESS: d �-D 5� rY'{ s PERMIT SR#. <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 ct. <br />License <br />�Q -7-Expiration Date: �` d <br />#: _ <br />i <br />Signature <br />Printed name: <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 />Carrier:Sl�`e-� a—1 Policy Number: <br />Vf� (Al( 6CADS-MD 1 �S$� <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, 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 />ADDITION SEtt 3706 OF THLABOR CODE <br />OS ION, INTEREST, ATTORNEY'S FEES, AND DAMAGES AS <br />PROVIDED FORIN SECTION <br />AUTHO IZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br />(signature ofC-57 licensed authorized representative), <br />hereby authorize (print name) <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 />0-L7-vc I ml <br />