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11/04/1999 14_:4.0 5095355 GEGLOGICAL TECHNI 6 PAGE 03 <br /> Ili <br /> I <br /> Sart Joaquin County Environttten 1 Maalth S}r+ticea.Unit IV Wel)Permit Application Supplement <br /> JOB ADDRESS: �J/�1 PERM17 SR#: <br /> � I i <br /> LICENSED CONTRACTORS DECLARATION (LCDj <br /> 1 hereby affirm that I am licensed under the prowslone or Chapter 13 tcommencing with Section 7000)of Division <br /> 3 of the Business and Proteasions Code and my iceeK In fulforce deect. <br /> tion DrtaLicense Expire <br /> - <br /> Data! I "I oMractor 1�✓�U nl'7��! <br /> - <br /> J <br /> Signature: Tom: <br /> Printed name: Ja <br /> I It >< Z 7 <br /> WORKERS'COMPENSATION DECLARATION <br /> 1 hereby affirm under penalty of peoury one of the following declarations: (CHECK ALL THAT APPLY) <br /> I have and wAi maintain a cereitcate of consent to selfinsurefor workers'compensation, as provided for ov <br /> Section 3700 of the Labor Code. for the perfarmance 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'compensatlon Insurance <br /> carrier and policy numbers are <br /> Csrrier: lUen F 04In Policy Number: Iyk/r'5`(�,05 <br /> _I 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 became subject to the workerscompensation laws of California, and agree that It I <br /> should become Subject W the workers'oompensation provisions of Section 3700 of the Labor Code. 1 shall <br /> iforthwith comply with thaee provisions. <br /> Date: alpnature: <br /> Printed Name: <br /> WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL.,AND SHALL SUBJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES LLP TO ONE HUNDRED THOUSAND DOLLARS <br /> IN ADDITION TO THE COST OF COMPENSATION.INTEREST,ATTORNEY'S FEES,AND DAMAG"AS <br /> PROVVtD]ED FOR IIN]SECTION 37D6 OF THE LABOR CODE. <br /> (C57 licensed sudtorimd representative), hereby <br /> authertis <br /> LL�U <br /> gn is San Joaquin County Well Permit Application on my behalf_ I understand this authorization Is valid fat <br /> year <br /> and la Nmitetl T4 tl»work plan dated on the Thant page of this+pplicatlon. <br />