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San Joaquin County Environmental Health Department Unit IV Well Permit Application Supplement <br />JOB ADDRESS: 1&,c_ 1'c3,- PERMIT SR#: 100)0 41I <br />CA1 <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 #: C -57 7 n 5-6 Expiration Date: - 0 <br />Signature: <br />Date: — - 04 .ntractor c\c-s& t <br />Vas% a. <br /> Title: 1-Nno,,00.(1 <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 />X 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: P\ \(\-_k(NV 01/44-113n Policy Number: 0,1) (ILO ',Y)8',)) <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 prov. 'ons of '! ction 3700 of the Labor Code, I shall <br />forthwith comply with those provisions. <br />Signature: <br />Printed Name: \lox- e)-)a,p r\ <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 />AUTHORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <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 />8-29-02 / MI <br />Printed name: <br />Date: <br /> <br />q <br />)1- <br />Dde, <br />;usiEcl. <br />GEs <br />)T4 <br />-esentativ e), <br />is valkd for