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of _L <br /> lip <br /> San Joaquin County Environmental HHee!ie Department Unit IV Well Permit Alication Supplement <br /> 0i A <br /> JOB ADDRESS : rrl3 5. G ppPERMIT SRI: C <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 ik 7 Expiration Dale: JO �3 / //0 <br /> Date : Contractor. l LL 1 A <br /> Signature : bl71t1e : <br /> Printed name; <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the following decleratlons: (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 permit is issued , <br /> vI have and will maintain workers' 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; <br /> n / <br /> Carrier: C, � !' J Policy Number: C <br /> rv .o <br /> I certify that In the performance of the work for which this permit is issued , ( shall not employ any person in <br /> any manner so as to become subject to the workers' compensation laws 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. 1 <br /> Dale: _ $ignaWre: � <br /> Printed Name: y7i 0?a4' lea , C C� ��r✓ <br /> WARNING: FAILURE To SECURE WORKERS' COMPENSATION COVERAGE 19 UNLAWFUL, AND SHALL SUBJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> ($100,000J, IN ADDITION TO THE COST OF COMPENSATION, INTEREST, ATTORNEY'S FEES, AND DAMAGES As <br /> PROVIDED FOR IN SECTION 3708 OF THE LABOR CODE, <br /> AUTHORIZATION FOR OTHER THAN Ca57 SIGNING PERMIT APPLICATION <br /> I, (signature ofCi7 licensed authorized representallve), <br /> herebyauthorize (prinlneme) dfL'✓/Z <br /> to sign this San Joaquin County Well Permit Application an my behalf- I understand this authorization is valid for <br /> Cine (1 ) ynai and Is limited to the work Ptah dated on the front page of this application, <br /> L-:+0.02 <br />