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San Joaquin County Environmental Health Department Unit IV Well Permit Application Supplement <br /> dv�3c.G•+ <br /> JOB ADDRESS: PERMIT SR#: <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 <br /> andProfessionsCode and my license is in full force and effect. <br /> License* �J� 4 -J J ! Expiration Date: ► C) 3 i I <br /> Date: Contractor: XLL- W5LL A Dpi 1>VUU r <br /> Signature• Title:62 <br /> �J•Sld�td`� <br /> Printed name: <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 /> 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 ar : <br /> Carrier: Policy Number: 7/3 — 001 :2OGb -07 <br /> 1 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 /> Expiration Date: / Signature: <br /> Printed Name: / L e— <br /> WARNING: FAILURE TO SECURE WORKERS' COMPENSATION CO ERAGE 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 /> AU HORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> 1. (signature ofC-57 licensed authorized representative), <br /> hereby authorize(print name) SEE[t L7. ]Cep t,c� dol?iZ,o.af u 1�oavr[ � 1 N c <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 /> 8-29-021 MI <br /> EHD 29-02-001 <br /> hi??rn4 <br />