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401* ,/ <br />v 01/ <br />San ,.loqu in County Enviroinnental Health Department Unit IV Vitali Permit Application Supplement <br />JOB ADE)R,ESS: 7/--/ 9 N.L.-30,-,6, fl_j PERMIT SRIt: r <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 IiCenee is in full force and effect <br />Ucens-e e 15 lig ExpitAtort Date: <br />Data:cant actor ti lba <br />Signature: Title: C.121.... <br />Printed name: )777;f___. <br />WORKERS' aomPENATioN DECLARATION <br />I hereby affirm under penalty of perjury one Of the following declarations: (CHECK ONE) <br />I have and will maintain a certtficateof cOneent la If i _ 8 e...,1151,Lre for workers' compensation-, as provided for b <br />c <br />y the :Section 3700 of the Labor Code, for peiformarirx of the wprk. [or MAO this permit is issued. <br />I have and will maintain workers' CorgpensatiOninsurance, as required by Section 3700 of the Labor Code, <br />for the performance of the work for whItglifitS-iPertn It iflissued. Myworkars' compensation insurance <br />carrier and policy numbers e. <br />Carrier: A)61 s • <br />1 certify that in the performance of theE1 -wO4 for whfch this permit is issued, I shall not employ any rson in , le <br />any manner so as to become subject talke•WOricies compensation laws of California, and agree that if I . <br />should become subieol to the workers•dorapensation provisichS-of SeoUptl .3700 of the Labor Qode,1 04 [ <br />forthwith corn ply with those provisiOns...:,.. . • <br />atia:,*licy Number: Ft Vk '71 L ! <br />Expiration Date: <br /> <br /> Sign &tint <br />F'rIntext Name: <br /> <br />WARNING: FAILURE TO SECURE VVORKERS' COMPENSATION COVERAGE-IS UNLAWFUL, AND SHALL SUBJECT <br />AN EMPLOYER TO CRIMINAL. PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS. <br />(4100,000.), IN ADDITION TO THE COST OF COMPENSATION, INTEREST, ATTORNEY'S FEES, ANTI DAMAGES AS <br />PROVIDED FOR IN SECTION 3706 OF THE LABOR.COIDE, <br />AUTHORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br />e/J jsinature ofC-S7 licensed authorized representative), <br />hereby authorize (print n4 <br />to sign this San Joaquin County Well PennitApplicatIon on my behalf. I understand this authorization is valid for <br />one (I) year and Ls limited to the work plan dated on the frcfnt-pase of this application. <br />8-29-021 Nil <br />Eat129-07-001 <br />6/224-1