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San Joaquin County Environmental Health Department Unit IV Well Permit Ap`plicatiioonn Supplemental <br /> JOB ADDRESS: 30 ! 23 13e .d an .' 6��(F f1 e/pE RMIT SR iv � # D J 7 <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 and Professions Code and my license is in full force and effect. <br /> License#: ( coti Exp Date: I i i 11_0 I o <br /> Date: (04 <br /> Contractor: <br /> Signature: <br /> Signature: Title: cyo 1 ✓ <br /> h <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 /> Carrier.-S10, A :T__ _ Policy Number: b—L) Uz—IOC <br /> I certify that in the performance of the work for which this perm it 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' comp nsation provisions of Section 3700 of the <br /> Labor Code, I shall forthwith comply with those provisio s. <br /> Exp. Date: I O Q Signature: <br /> T 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 /> 4aut' <br /> IZA ION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> I• (signature of C-57 licensed authorized representative), <br /> he (print name) C 1 S to <br /> sign this San Joaquin county Well Permit Application on my be If. 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 /> 8129/021MI <br /> EHD 2901 11/307 <br /> WELL PERMIT APP <br />