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12/07/2004 09:54 91686104» <br /> SECOR 'v PAGE 03/04 <br /> San Joaquin County Environmental Health Department Unit IV Well Permit Application u pt <br /> JOB ADDRESS: 1(.1111. � i <<ak�t' LA 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 Division <br /> 3 of the Business and Professions Code and my license is in full force and effect, <br /> License#: /l W 9 l / Expiration Date: 77�C6 <br /> Date' <br /> 102-7 -CJ`Y Contractor / V'xYII ,men L Py>41 C� <br /> O r-� <br /> Signature: /n Dj� (� -"'-r"��Title:�'4 111 <br /> Printedname: C' O/JG /it1 G- F I�iJooL)Lo A-142t, <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the following declarations: (CHECK ONE) <br /> I have end 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 permit is Issued. <br /> I have and will maintain wodters' compensation insurance,as required by Section 3700 of the Labor Code, <br /> for the performance of the work for which this permit Is Issued, My workers'compensation insurance <br /> carrier and policy numbers are: 6 <br /> Carrier: 65 IQ+F,6W inn _PoNcyMumber: rIId-{yCIW-2022) - <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 laws of Califomia, 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 Date: d e 5 Signature: <br /> Printed Name: l'o ..i C z A) F I UOyD w r�Q rJ <br /> WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE 16 UNLAWFUL,AND SHALL SUBJECT I <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CML FINES UP TO ONE HUNDRED THOUSAND DOLLARS III <br /> P <br /> SROV DED FOR IN SECTION 3106 OF T LABOR AODITION TO <br /> 31OFNSATION, INTEREST,ATTORNEY'S FEES,AND DAMAGES AS <br /> AUTHORIZATION FOR OT R THAN C-57 SIGNING PERMIT APPLICATION <br /> f (- i 1+ Jv 1-�-Q (algnature o(C.67 licensed authorized representative), <br /> /� ' <br /> hereby authorize(Print name) - 41`-e`—, "`-4' r, <br /> to sign this San Joaquin County Well Permit Application on my behaf,, I understand this authorizatlon Is valid for <br /> one(1)year and Is llmlted to the work plan dated on the front page of this appllestion, <br /> �E-29-021 MI.29-021 MI <br /> al{n 29.02.01 <br /> anvo4 <br /> 4:00@] euTTT1JG paampeoM 00£6hL£LOL XFd TT:TT h00Z/L0/9T <br />