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San Joaquin County Environmental Health Department Unit IV Well Permit Application Supplement <br />/�F S r / 1901/& {° 32 <br />JOB ADDRESS: 2112sz- "�n[t�� revtn s� i PERMIT SR#: --Q j2 lO 33 <br />�1+'UGtL�avt. <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 #. C `••� �7 1 S' 0 Expiration Date: 1-31-08 <br />Date: 5 ~ -D U <br />Signature: All <br />Printed name: _ Ve/v� <br />ractor. a a S Co-c(e D rj I I i", I m, <br />;= Title: <br />WORKERS' COMPENSATION DECLARATION <br />I hereby affirm under penalty of perjury one of the following declarations: (CHECK ONE) <br />_ 1 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: L <br />Carrier: �" .(. t �d �''� 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 Califomia, and agree that if I <br />should become subject to the workers' compensation provisions of Se ' n 3700 of the Labor Code, I shall <br />forthwith comply with (hose <br />provisions. <br />Expiration Date: S.� f 0 1 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.), 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 />AUTO ORIZAT)ON-IqR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br />I, (signature ofC57 licensed authorized representative), <br />hereby authorize (print name) _ � t fiQ- 5 1, �t�Yl &44,4m <br />to sign this San Joaquin County Well Permit Application on my bohalf. 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 />8-29-021 MI <br />IiNU 29.02- i <br />6122AM <br />