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I 11112.0____ <br />I01 <br />te-) Ae <br />San .;oaquin Count Environmental Health De artment Unit IV Well Permit Application Supplemental <br />2.45 <br />_OS ADDRESS: 111 RMIT SR # <br />5-f-rk Pc— <br />LICENSED CONTRACTORS DECLARATION (LCD) <br />nereDy affirm that I am licensed under the provisions of Chapter 9 (commencing with Section 7000) of <br />Division 3 of the Business and Professions Code and my license is in full force and effect. <br />_,Ge,r1se Exp Date . I/ 3).17_01p <br />Contractor PRC.451010 SAMPL-LeJeri I!Jr- <br />Title 1- CA-T7 0".1 1-1 EWA G <br />Name 2kEf\-)0.6 LW-A-WT:0g) <br />WORKER'S COMPENSATION DECLARATION <br />oy 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 <br />provided for by section 3700 of the labor Code, for the performance of the work for which this <br />permit is issued. <br /> nave and will maintain workers' compensation insurance, as required by Section 3700 of the <br />Labor Code, for the performance of the work for which this permit is issued My workers' <br />compensation insurance carrier and policy numbers are . <br />E t2-1 nyr kno,k <br />Carrier: Sir Policy Number: LJLI1L (CPT -) <br />Ni Su Com Ott •Ji <br />certify that in the performance of the work for which this permit is issued, I shall not employ any <br />person in any manner so as to become subject to the workers' compensation law of California, and <br />agree that if I should become subject to workers' compensation provisions of Section 3700 of the <br />Labor Code. I shall forthwith comply with those provisions. <br />g 1 3a-Le: fp/ 3 Vi 1-0(,)ci Signature: <br />Print Name: g e-f-) QA- c*Avvf-70 1) <br />.',ARNING FAii.i;RE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL SUBJECT AN EMPLOYER TO <br />CRIMINAL PENALTIES AND CIVIL FINES UP TO $100,000, IN ADDITION TO THE COST OF COMPENSATION, INTEREST <br />ATTORNEY'S FEES, AND DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE <br />UM TION-FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br />ri (signatur f Cf5.7 licenskd auth rized rvresentative), <br />5ereby authottetprintireme), — k ‘ \ <br />Il ill <br /> I O 7 , to <br />sign this San Joaquin county Well Permit Application on my behalf. I understand this authorization is valid <br />for one year and is limited to the work plan dated on the front page of this application. <br />31291021M1