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lG444.� <br /> San Joaquin County E vironmental Health Department Unit IV Well Permit Application Supplemental <br /> JOB ADDRESS:°060. 301/ Al. /Se^ Xl� ,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 <br /> Division 3 of the Business andel Professions Code and my license is in full force and effect. <br /> License#: J 661 Exp Date: (,3 I J2,0 1 L) <br /> Date: tU /l v Contractor: i / l /I✓1 !_7! _ <br /> Signature: ✓I "//i Title: i�PA z( �6�l� - <br /> J <br /> Print Name: <br /> WORKER'S 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 <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 /> I o 8 07�1� I <br /> Carrier: b (� hf _ 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 should become subject to workers' compensation provisions of Section 3700 of the <br /> Labor Code, I shall forthwith comply with those proviS n (� <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,A AMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. <br /> AU IZA1U N OR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> (signature of C-57 licensed authorized representative), <br /> hereby authsize rint name) i L , S GSL to <br /> Sig n this Sa quin county Well Permit Application on my behalf. I un rstand this authorization is valid <br /> for one year and is limited to the work plan dated on the front page of this application. <br /> 81291021MI <br /> EHD 29-01 1115101 WELL PERMIT APP <br />