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610 -,#L <br /> San Joaquin County Environmen Health <br /> Department Unk IV Well Permit APPI�atiouPPlemental <br /> Q PE RMIT SR# <br /> JOB ADDRESS: 6,& <br /> IVAI 209•/50 . 27 guic <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 #: ,a6 Cr-I _E xp Date: )r C> / <br /> Date: �l �7 _Contractor. <br /> Title: <br /> Signat <br /> Print <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 thi s <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 thi s permit is issued. My workers' <br /> compensation insurance carrier an d policy numbers are: <br /> Carrier: <br /> q{e �u .��l Policy Number: S <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 subjectotthose pworkocompensation <br /> p nssation provisions of Section 3700 of the <br /> Labor Code, I shall forthwith com ply <br /> Exp. Date: rr a Signature: � — <br /> •— <br /> Print Name: <br /> ECT AN EMPLOYER <br /> WARNING:FAILURE IAL PENwT ES AND CIVIL FINES UP TO$100,000-IN ADDITION TO THE OS OF COMPRAGE IS UNLAWFUL,AND SHALL ENSATION IN INTEREST,TO <br /> ATTORNEY'S FEES,AND DAMAGES AS PROVIDED FOR IN SECTION 3700 OF THE LABOR CODE. <br /> AUTHORIZATION FO ` NSR THAN C-57 SIGNING PERMIT APPLICATION <br /> (signature of C-57 licensed authorized representative), <br /> 1, S L ,to <br /> hereby authorize(print name) <br /> r <br /> sign this San Joaquin county Well Permit A lication 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 /> e zsro7 Nll <br /> WELL PERY17 <br /> EM2901 111 7 <br />