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San Joaquin County Environmental Health Department Unit IV Well Permit Application Supplemental <br /> KPERMIT SR# <br /> JOB ADDRESS: �� � 1 QA- <br /> LICENSED <br /> � � <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> I hereby affirm that I am licensed under the provisions of Code and my license is in fullrforce and encing wleffectction 7000) of <br /> th <br /> Division 3 of the Business and Professions l <br /> Exp Date: <br /> License#: <br /> Date: <br /> 5 `� Contractor: <br /> ( Title: <br /> Signature:' 2 NA <br /> Print Name: <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 /> compnsation insurance, as ired <br /> ction <br /> I have and will maintain workers' <br /> of thee <br /> for which this pe <br /> compensation <br /> b <br /> s issued.eMy wore of the <br /> Labor Code, for the perform <br /> compensation insurance carrier and policy numbers are:���) <br /> Carrier:. e �` ,��!� -�-�---- <br /> Policy Number: •�t V [_ <br /> erm <br /> t is issued, I <br /> l not employ any <br /> s p <br /> as to to bjectof the work for vtolthech twlorkers'Icompensation hlal <br /> I certify that in the performance of California, and <br /> person in any manner so <br /> agree that if I should become subject to workers' compensation provisions of Section 3700 o t e <br /> Labor Code, I shall forthwith comply with those provisions. <br /> Exp. Date: E C Signature: <br /> Print Name: <br /> MPLOYER <br /> WARNING:FAILURE TO SECURE WORKEFINES UP TO COMPENSATION <br /> $100,000E N ADDITION THE COST OF COMPENSATION AWFUL,AND SHALL SUBJECT ANENTEREST,TO <br /> CRIMINAL PENALTIES AND CIVIL <br /> ATTORNEY'S FEES,AND DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. <br /> AUT IZATION FOR OTHER THAN C-57(signature <br /> a5ure oGC--5NG licensed lu authorized edl representative), <br /> I, <br /> to <br /> hereby author ze(print name) <br /> sign this San Joaquin county Well Permit Application on my behalf. I understand this authorization is valid <br /> for one year and is limited to the work plan dated on the front page of this application. <br /> ar�arn�rnnl —_ <br /> WELL PERMIT APP <br /> EFID 29-01 1115107 <br />