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San Joaquin County Environmental Health Department Unit IV Well Permit Application Supplemental <br /> JOB ADDRESS: �1- ! 0 MIT SR <br /> 1 <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> I hereby affirm that I am licensed under the provisions of Chapter 9(commencing with Section 7000)of <br /> Division 3 of the Buq85siness and Professions Cade and my license is in full force and effect. <br /> License#: .,_.___- -- _ E xp Date: _�31 — <br /> Date: E� - _ _ _ Contractor: <br /> Signature: _. Title: <br /> Print Name: DylgwiQec (dhPl� <br /> WORKER'S COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the following declarations: (check one) <br /> _ I have and wi It 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 /> I have 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 /> Carrier: Policy Number: <br /> I 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 shoutd become subject to workers' compensation provisions of Section 3700 of the <br /> Labor Code, I shall forthwith comply with those provisions. <br /> Exp. Date:_ . Signature: <br /> Print 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$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 /> RIZ T1WF0 OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> I (signature of C-57 licensed authorized representative), <br /> hereby authorize(print name) � LZ—E E4iir< C ra�� ,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 /> R129f�2fMl <br /> WELL PERMIT APP <br /> EHD 2901 1115W <br />