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I( <br />1E37 <br />San Joaquin County Environmental Health Department Unit IV Well Permit Application Supplement <br />JOB ADDRESS: ‘y z CAP,L0L- PERMIT SR#: oto/24/6 <br />1-POI 55vo- <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 #: Z-Z-7 Expiration Date: bi o j ?fen GA-: ti 03 <br /> <br />Signature: <br />Contractor:n--c.)1f 1 tCEj2 Ce-..c, v;t- Di) iv) P4 74V <br /> Title. do ec.„7 c e, /05, 's f <br />Date: CC) — I k - c.)2 <br /> <br />Printed name: 1;filic1i41 J, cukil 4-k <br /> <br />WORKERS' COMPENSATION DECLARATION <br />I hereby affirm under penalty of perjury one of the foilowing 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 <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 in urance <br />carrier and policy numbers are: <br />574--Q, cir3 iopk fog+ i‘ 0 0 <br />Carrier: 'In5vr,ANCIZ. Rive0 Policy Number: <br />V \., 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. 09 02- 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 /> (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 />1-25-02 / MI <br />H /97y7 / 2.003 <br />C,J\Y <br />