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r l <br /> FiOB <br /> n Joaquin County Environmental Health Department Unit IV Well P rmit Application Supplemental <br /> �� pV PERMIT SR# ��/ <br /> DDRESS: <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> I hereby Division 3 affirm the Business 1 am licen ness andsed under the provisions of Professions Code and my license s in full force and withSection7000) of <br /> �� Exp Date: E� <br /> License#: /y / 1 06k 04 - <br /> Contractor: <br /> Date: O�S <br /> itle: <br /> Signature: <br /> Print Name: C+�r?iSTo � <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, fortheinsurancecarrier rfo of he work for whih policy numbers arehis permit is issued. My workers' <br /> comp <br /> Carrier: <br /> Sftvk&k - 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 /> Labor Code,11 shallf orthwith csubject to omplywi h thosesproompensation provisions Section 3700 of the <br /> Exp. Date: V?) �d� I " ' _ Signature: <br /> Print Name: <br /> WARNING:FAILURE TO SECUFCRIMINAL PENALTIES AND CEVIL FINES UP TO$100,00,NA ADDITION TO THE COST OF COMPENSATION,GE IS UNLAWFUL,AND SHALL SUBJECT AN EINTERES R TO <br /> SECTION 3706 OF THE LABOR CODE. <br /> ATTORNEY'S FEES,AND DAMAGES AS PROVIDED FOR IN <br /> ION FOR OTHER THANgC-57 SIGNING <br /> IG P sed IT APP dl rep IOen(sitative), <br /> I ,to <br /> hereby authorize(print name) <br /> 11 CY MRY <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 front page of this application. <br /> R1291021MI <br /> • WELL PERMIT APP <br /> EHD2901 WM7 • <br />