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San Joaquin County Environmental Health Department Unit IV Well Permit Application Supplement <br />JOB ADDRESS: ZZ/ I kit Wi LG:3,4) PERMIT SR#: <br />LICENSED CONTRACTORS DECLARATION (LCD) <br />hereby affirm that I am licensed under the provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business <br />3nd Professions Code and my license is in full force and effect. <br />_icense #: 5 /2.2- 'e Expiration Date: <br />Date: (61 <br /> <br />Contractor: Sped -fii,kirt /07 L. • <br /> <br />Signature: Signature: <br />Printed name: (eikife_ (CI e,r" <br />Title: <br /> <br />WORKERS' COMPENSATION DECLARATION <br />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: V4fiek-€40 Fccv kui-• 1:1 - Policy Number: 7( le /..e <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 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: 61710 Signature: <br />Printed Name: <br />WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL SUBJECT AN EMPLOYER TO <br />CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS ($100,000.), IN ADDITION TO THE COST OF <br />COMPENSATION, INTEREST, ATTORNEY'S FEES, AND DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. <br />AUTHORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br />Ji Lle4.kPJ (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 />8-29-02 / MI