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00 C051pZW <br /> (2, <br /> San Joaquin County Environmental Health Department Unit W Well Permit Application Supplemental <br /> JOB ADDRESS: CJUX" PERMIT SR <br /> A <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> I hereby affirm that I am licensed under the provisions of Chapter 9(commencing with Section 7000)of <br /> Division 3 of the Business and Professions Code and my I icense is in full force and effect. <br /> Ko(�) 9 <br /> License#: Exp Date- IaLd lo <br /> Date: S Contractor: <br /> Signature, 1 <br /> Title: <br /> Print <br /> WORKER'S 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 <br /> provided for by section 3700 of the labor Code,for the performance of the work for which this <br /> permit is issued. <br /> I have and will maintain workers'compensation insurance, as required by Section 3700 of the <br /> Labor Code,for the performance of the work for which this permit is issued. My workers' <br /> compensation insurance carrier and policy numbers are: <br /> Carrier: Policy Number: <br /> I certify that in the performance of the work for which this permit i s issued, I shall not employ any <br /> person in any manner so as to become subject to the workers'compensation law of Califomia,and <br /> agree that if I should become subject to workers' compensation provisions of S ection 3700 of the <br /> Labor Code, I shall forthwith comply with those provisions. <br /> Exp.Date: ) cis Signature: <br /> Print Name: I <br /> WARNING:FAILURE TO SECURE WORKERS*COMPENSATION COVERAGE 13 UNLAWFUL,AND SHALL SUBJECT AN EMPLOYER TO <br /> CRIMINAL PENALTIES AND CIVIL FINES UP TO$100,000,IN ADDITION TO THE COST OF COMPENSATION,INTEREST, <br /> ATTORNEY'S FEES,AND DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. <br /> A�6HfORI ON FOR)OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> -67 1' ensed authorized(signature of C ed representative), <br /> liereby authorize(print nam e-QGNANCT-ec to <br /> sign this San Joaquin county Well Permit App cation on my behalL I 6derstand this authorization is valid <br /> for one year and is limited to the work plan dated on the front page of this application. <br /> 81"1021MI <br /> EHD29-01 1119D7 WELL PERMIT APP <br />