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�. U2/22/n,8Q5,,' ,10:,43 9168610430 5ECOR <br />f d6. <br />PAGE 02/02 <br />San Joaquin County Environmental Health Department Unit IV WL -11 Permit Application Supplement <br />JOB ADDRESS: <br />/z-?3c—.4,.c►.�►(,,.,r PERMIT $R#/"�_ _ <br />LICENSED CONTRACTORS DECLARATION (LCD) <br />I hereby affirm that I am licensed under the provisions of Chapter 9 (commencing with Section 7040) of Division <br />3 of the Business and Professions Code and my license i$ in full force and effect. <br />License #: 'Ct 7 � Expiration Date: <br />Date: Contractor: <br />Signature: / Title <br />/'/z�7�rG7/� f%Ygncp <br />Printed name, (1f41.11 rA,00 �J% <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 certifioete of consent to self -insure for workers' compensation, as provided for <br />by Section 3700 of the Labor Code, fur the performance of the work for which this permit i6 issued. <br />I have and will maintain workers' compensation insurance, as required by Section 3700 of the Labor Code, <br />for the performanoa of the work fvr which this permit is issued. My workers' compensation insurance <br />carrier and policy numbers are - <br />Carrier: Policy Number: e j01� 0 <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 worksm' 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 />1=xpimtlnn Date: — ignature: <br />g" UI v,/Printed - ' <br />Kama: <br />WARNING: FAILURE 'i D SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL SUBJEGT <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 DAMAQED AS <br />PROVIDED FOR IN SECTION 3746 OF' THE LABOR CODE. <br />AUTHORIZATION FOR OTHER THAN C-57 SIGNING PERMIT.APPLICATION <br />I, (signature ofC.S7 licensed authorized represuntativel, <br />hereby authorize (print name) 4 _]SrDwn ok- 15Fe0i;L Xa±gfM_*",1DA.LJ <br />to sign this San Joaquin County Well Permit Application on my behalf. I understand this authorization Is valid far <br />one (1) year and Is limited to the work plan dated an the front page of th]3 application. <br />8-29-021 MI <br />C140 2902.001 <br />6/22104 <br />Z© 39dd JNI_l­IIdG 993�19 Z©E©CTESZ6 85:8Z S©©Z/ZZ/Z8 <br />