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��SBS"1�inw-lk•QP"/' <br />e)awedL <br />San Joaquin county Environmental Health epartment UD* IV Well ftrmit ApplilicVation Supplement <br />JOB ADDRESS:_' VN,1 i(�'IIG.'!;- i:�; 1. .�+ : qG+�'. PERMI SR#: 3 <br />4r�44,v <br />•r <br />>a 7h!i <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 #: �03 YJ Expiration Date: ha /01 <br />Date: aq0 tor: � Qr L L <br />Signature: Title: V. <br />Printed name: (A , v--\C,(,J IC <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: ,C ,Ti.(..n Policy Number: :Z 1315 3-10 -7 <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' co lifornia, and agree that if I <br />should become subject to the workers' compen provisions of S 1370 of the Labor Code, I shall <br />forthwith comply with those provisions. <br />Expiration Date: 1 -,Al Signature: <br />Printed N <br />WARNING: FAILURE TO SECURE WORKS ' COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL SUBJECT <br />AN EMPLOYER TO CRIMINAL PENALTI AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br />($100,000.), IN ADDITION TO THE CO OF COMPENSATION, INTEREST, ATTORNEY'S FEES, AND DAMAGES AS <br />PROVIDED FOR IN SECTION 3706,OF THE LABOR CODE. <br />AUTHORIZATICKFOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br />iereby authorize (print name <br />t <br />nature ofC-57 licensed authorized representative), <br />o sign this San Joaquin County Well Pence Application on my behalf. I understand this authorization is valid for <br />ine (1) year and is limited to the work plan dated on the front page of this application. <br />-29-021 MI <br />HID 29-021101 <br />W22'04 <br />