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San Joaquin County Environmental Health Department Unit IV Well Permit Application Supplement <br /> JOB ADDRESS: 5 S PERMIT SR#: <br /> LICENSED CONTRACTORS ')ECLARATION (LCD) <br /> I hereby affirm that I am licensed under the provisions of Chz pter 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#. ( �� ` J � Expiratic i Date: - <br /> Date: I �1� 'Q'I Contractor: <br /> Signature: V-0 <br /> �,,..�_..-._cam ` Title: <br /> Printed name: �U � 1 <br /> WORKERS' COMPENSATI DN DECLARATION <br /> I hereby affirm under penalty of perjury one of the following (leclarations' (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 /> X I have and will maintain workers' compensation insuran :e, 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 a <br /> re <br /> : ` J� <br /> Carrier: Fs-vo—t1-- ��✓ Policy Number: OI 1000O <br /> I certify that in the performance of the work for which th s permit is issued, I shall not employ any person in <br /> any manner so as to become subject to the workers' co npensation laws of California, and agree that if I <br /> should become subject to the workers' compensation p ovisions of Section 3700 of the Labor Code, I shall <br /> forthwith comply with those provisions. <br /> Expiration Date: (� Signature:_ '"--^�~'-" .----".���---_ •�-"�"-""-�"- <br /> Printed Name: <br /> WARNING: FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES I IP 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 Q,IBER THAN C-!i7 SIGNING PERMIT APPLICATION <br /> ~`-"' �^ ;signature ofC-57 licensed authorized representative), <br /> hereby authorize(print name) ��A , <br /> to sign this San Joaquin County Well Permit Application on n y 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 /> 8-29-021 MI —-- <br /> EHD 29-12-001 <br /> 6122/04 <br />