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San Joaquin County Environmental Health Department Unit IV Well Permit Application Supplement <br /> JOB ADDRESS: I40q 0, (.GrWT-,f( 0, PERMIT SR#: 44.�y� Z <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#: I//des ?6 5 Expiration Date: I a - 31_D(o /J <br /> Date:9 ".3 -0 Contractor: FI SC'N n✓I ✓✓ C)n Vln e w"t�w <br /> Signature:a Title: 62t1g_ LL <br /> Printed name: , I ]�I✓1 CI �� 3 <br /> 0 <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 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 p��olli� pt1icy numbers are: <br /> Carrier: t3Td. e cn� IP Policy Number. �5_;�tO,)LOs-03 <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 /> Expiration Date: b��_�% Signature: �f <br /> ------------- <br /> Printed Name: _?)avi1 St�4_ __ <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 /> ($100,000.), 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 /> I, !J <br /> er Vi 6'I i3C t 1 1 `' (signature ofC-57 licensed authorized representative), <br /> hereby authorize(print name) T"'L�'T T I"i t�.C ,� <br /> to sign this San Joaquin County Well Permit Application on my behalf. I understand 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 /> 8.29-02/MI <br /> EHD 29-02-001 <br /> 6/22/04 <br />