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San Joaquin County Environmental Health Department Unit IV Well Permit Application Supplemental <br /> JOB ADDRESS: 14253 50"TH q'09?MT WAY PERMIT SR # <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> I hereby affirm that I am licensed underthe provisions of Chapter 9(commencing with Section 7000)of <br /> Division 3 of tthhe-Business and Professiio`�ns Code and my I cense is in full force and effect. <br /> License#: fl�i� f — —1 Exp Date: ' 31 — 20)o <br /> Date: , t'� ZU T 2z->W) Contractor..-OW U- k owndlcy1 (l i <br /> Signature:- �/� Title: _P(e <br /> Print Name: ���7U.�7� SIS q(�ily <br /> WORKER'S COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the followini1 declarations: (check one) <br /> _I have and will maintain a certificate of consent to !;elf-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 /> X I have and will maintain workers'compensation inE urance, as required by Section 3700 of the <br /> Labor Code,for the performance of the work for wl Iich this permit is issued. My workers' <br /> compensation insurance carrier and policy numbers are://�� f� <br /> Carrier: \J 'e Ay�C� Policy Num)er: 0 -loco <br /> 1 loco ^ (119 <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 1 ie workers'compensation law of California, and <br /> agree that if I should become subject to workers' c tmpensation provisions of Section 3700 of the <br /> Labor Code, I shall forthwith comply with those prc visions. <br /> Exp. Date: -2,01 D Signaturey <br /> Print Name: _ Jk ± <br /> WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAG:IS UNLAWFUL,AND SHALL SUBJECT AN EMPLOYER TO <br /> CRIMINAL PENALTIES AND CIVIL FINES UP TO$100,000,IN AC DITION TO THE COST OF COMPENSATION,INTEREST, <br /> ATTORNEY'S FEES,AND DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. <br /> �,AUT�I��TI^" n_R nTHER THAN C-51 SIGNING PERMIT APPLICATION <br /> 1, 1�� (signatu a of C-57 licensed authorized representative), <br /> hereby authorize(print name) r N a t l ,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 frog t page of this application. <br /> R/2902/MI <br /> E101941 11f."7 <br /> WELL PEiUaT A(4 <br />