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11 to er�eir� ie•ei.�ri rr[U, I U 17GJbtidU_')Ud F'.U4 <br /> San Joaquin County Environmental Health Services, Unit IV Well Permit Application Supplement <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 and Professions Code and my license is in full force and effect. <br /> License#: yo 9/,,9 L, ^ Expiration Date: <br /> Date:_ < <t 200 1 Contractor: <br /> Signature• 6�d/ Title: o o s <br /> Printed name: 0L-�A)� �a <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the following declarations: (CHECK ALL THAT APPLY) <br /> I have and will maintain a certificate of consent to self-insure for workers'compensation, as provided for by <br /> 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 are: <br /> Carrier: ?ad /Su r4nC� (1'e Policy Number: 4�;Z <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 become subject to the workers'compensation laws of California, and agree that if 1 <br /> should become subject to the workers' compensation provisions of Section 3700 of the Labor Code, 1 shall <br /> forthwith comply with those provisions. <br /> Date: Z-16 — Signature: <br /> Printed Name:�,r9y�✓ <br /> WARNING: FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SU13JECT <br /> AN EMPLOYER TO CRIMINAL.PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> ($900,000.), IN ADDITION TO THE COST OF COMPENSATION,INTEREST,ATTORNEY'S FEES,AND DAMAGES AS <br /> PROVIDED FOR 1N SECTION 3706 OF THE LABOR CODE. <br /> 1, A� ,e,2--> (C-57 licensed authorized representative),hereby <br /> authorize �A�y � <br /> to sign this San Joaquin County Well Permit Application on my behalf. I understand this authorization is valid for <br /> one 9 year and is limited to the work plan dated on the front page of this application. <br /> I <br /> I <br /> i <br /> f <br /> r <br /> TOTAL P.04 <br />