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O/20/2@00 09:52 2094683433 <br />San Joaquin County Environmental Health-Services, Unit IV Well Permit Application Supplement <br />JOB ADDRESS: iOS I . VA-A-r— PERMIT SR#: <br /> <br />5 -k-CLAC1-e) ,C j3c, <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 #: 1 UD C' -71— Expiration Date: _‘) I 3\ 1 I <br />Date: 1 C) 1 Contractor e, c <br />Signature: Title: <br />Printed name: 10' <br />WORKERS' COMPENSATION DECLARATION <br />I hereby affirm under penalty of perjury one of the following declarations. (CHECK ALL THAT APPLY) <br />I have and will maintain a certificate of consent to self-insure for workers compensation, as provided for by <br />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: Vi CVO (L. Policy Number: LOC- \ cmc, jr, 'A <br />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: <br /> <br />Signature: <br /> <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 />(C-57 licensed authorized representative), hereby <br />authorize A ‘. wx S( y -)( <br />to sign this Sari 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 />FIFTH FLOOR PAGE 03 <br />fk 2_i-kM