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10-05-19 5 8: S 1 AP FROt•1 P. 1 <br /> Ir ou:lcl "P-ro Rr a i y'.=:T"- � FWD"JE NO, . -209 83S 9e.8Z �. 29 20'M 10:r>:AM P2 <br /> San Joaquin County Etzvitanmental Health 17epartment Ur it f Well Permit Application Supplement <br /> tom$/ CwGrrSTvC { <br /> � <br /> f i <br /> t <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> r <br /> I hefe4.i affirm t"W;2 am i.rensed unMer the 7 mvisions sf C,�apter�(cornmencir:g with Section 7000)of D3 visian <br /> 3 of thr Susi;.ass aced.PrC4'Ss.5s3�3 44d 'an#rrry iicen5e;s in fuli{arce and tf act <br /> 5 Expiration Efate-� 3[ ` <br /> UCH a56#: ! , 1A <br /> Title: <br /> fPrinted naane: <br /> WORKERS.''COMFENZIATION DECLARATION <br /> a <br /> 1>rLr�:ov dff rm owner p+ertai:'y ol perpry Q,e of the followin.;declarations: (CHF=CK ALL THAT APPLY) <br /> I have acid will rma'rtain a certificate of censent to self-insure for workers`CO.%,per,sattnr, as provider-for by <br /> Seebou, X709 of the Labor C:adr- to the performance of the vvurk for WNCi7 vt4.5 perrnit P4 i55vel' <br /> _1/f}gave and will rrtainTai 7 workers'coripersation in t.mrce, as required by Sec.tion 37WC,of the Labor Code, <br /> izor the oer~ormance ci the vror•M,trirwl'�ich this permit is'issued hlfy.�urhei s' car pe7�aFicy irsr,fat,ce <br /> i ' <br /> carrier and pnlicy nUmDGr5 are' <br /> � = 1 <br /> Carrier: Policy Number: f`� �P <br /> r 1 t Ll <br /> i cert',fy that in the periorrnarice cF fh-work for which this perrnit rs hived i 5hali no',employ any person in <br /> --- r 'CaliFarrria,and agree that if i <br /> any°r;onrier zo as to become sjt;j..ct'�th norkt s'corrperfs Liar laws o•, <br /> houlci become subsacf tp the work c.ornfrcrrsat;(,-n provisions of Seckn^0700 of the I.rbor Cade, t shay. <br /> torthw&carnp)y with those provisions <br /> gate.: <br /> Printed Narrle: <br /> i WARKING- 7-AILURG TO SECURE WORKERS'COMIPENSAMN-OQVERAGE f3 UNLAWPUL,AND$HALL SUBJECT <br /> AN>='MPLOYM TO CRIMINAL PENALTIES AND CIVIL,FINES UP TO ONE;HUNDREP THOUSAND DOLLARS i <br /> ($j00,0*q.):iN ADDITION TO THE COST OF COMPENSRTtON,;NTERt:ST.ATTOANIEWS FEEm.AND DAMAGES AS � <br /> { PROVIDED FOR IN SE40TION 3700 OF TKE LADOR CODE. <br /> 9 ry,!;�„t,;°.;.,.._...�SC�..�J. fgignature ofC-57 lscenmc�authorized�nprB�enEativ�), <br /> hereb;n'butharixe(print.riame) 6 P-`Go;z Y <br /> { trr sign tit's Sari.Jti glAin County Well Permlt Appiicgkthm cn my bll:half. t unde7stZIFId Chir,Qualaritatlon i5;vatsd for <br /> one,(i)year and'i%,11raited to the wdrlc rA3n datOd Ori the Smnt P299 of this appiietatiam I <br /> 1-25•Q2,1 <br /> Mi. <br />