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rf <br /> �5 5 <br /> w7 <br /> San Joaquin County Environmental Health Department Unit IV Well Permit Application supplement <br /> JOB <br /> � S� Tw <br /> JOB ADDRESS :, Ado? /020/ 's PERMIT SRW.- <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 #: b 57, 44) 2 Expiration Date: >/ O/::�, ) f, <br /> Date: Contractor; S/ [ <br /> Signature; vt 2 � TfUe: <br /> Printed name; <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the following declarations: (CHECK ONE) <br /> 1 have and will maintain a certificate of consent to self-insure for workers' compensation, as provided for <br /> bey Section 3700 of the Labor Code, for the performance of the work for which this permit Is issued , <br /> ✓ I 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 /> Carrier: C � a�' !'J') Policy Number: (f �2 T <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 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 /> Date: zf 2 $Ignature: <br /> Printed Name: y <br /> WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL SUBJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> ($9 08,000.), IN ADDITION TO THE COST OF COMPENSATION, INTEREST, ATTORNEY'S FEES, AND DAMAGES As <br /> PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, <br /> AUTHORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> 1, (signature efC-57 licensed authorized representative), <br /> hereby authorize (print name) G�Cl/IZ <br /> to sign this San Joaquin County Well Permit Application an my behalf. I understand this authorization is valid for <br /> tine (1) your and Is finiHed to the work plan dated on the front page of this application. <br /> . 14-.784721 izRP <br />