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h I �. 'I�• LVU.) II I -'t Imlvl 510°`,"-" \ Lnn ill I L\,n VIRONEX 14V V I .'AE 02 <br /> t <br /> San Joaquin County Environmental H93a4 Department Unit IV Well Permit Applicatlon upplement <br /> JOB ADDRESS. A ERMIT SR; <br /> ov <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 r Business and Professlons Code and my license is in full force and effect. <br /> License 4: —705q a-1Expiration Date: CSS I31� �yo� -� <br /> Date: 04/175 0 S Contractor. y I r®f1m <br /> Signature: Title: r� <br /> Printed name: VI—OA <br /> WORKERS' 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 provided for <br /> by Section 3700 of the Labor Code,for the performance of the work for which this perm(t is issued. <br /> 1 have and will maintain workers' compensation insurance,as required by Section 3700 of the Labor Code, <br /> for the performance of the work forwhich this permit is Issued. My workers'compensation insurance <br /> carrier and policy numbers are. <br /> Carrier: T(Af-)A C Stak Policy Number: W G Ifl 44 Sc(S11 _w <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 taws of California, and agree that if I <br /> should become subject to the workers'compensation provisions of Section 3700 of the Labor Code, I shall <br /> forthwith comply with those provisions. <br /> Expiration Signature: - <br /> Date: ow I is OtP <br /> Printed Name: <br /> WARNING: FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UN wFIX,AND SHALL SUBJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> ($100,000.),IN ADDITION TO THE COST OF COMPENSATION,INTEREST,ATTORNEY'S FEES,AND DAMAGES AS <br /> PROVIDED FOR IN SECTION 3706 OF THE LAROR CODE- <br /> AUTHORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> I. �/ �_. (sLgnature f 0.57 licensed authorizerepresentative), <br /> hereby authorize(print name)--Mfg k2e , <br /> to sign this San Joaquin Count71 Well PermIt:Applicatlon on my behalf. I understated this authorization is valid for <br /> one(1)year and Is limited to the work plan dated on the front page of this application. <br /> 3-19-031 MI <br /> RECEIVED TIME APR. 15. 11 :32AM <br />