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u .v caul 1q:U2 2094683433 FIFTH FLOOR PAGE 03 <br /> San Joaquin County Environmental Health Services, Unit IV W611 Pdrmit Application Supppllem nt <br /> JOB ADDRESS.=—,�D e1 PERMIT SR#: <br /> y"J`.,4 <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#: 9-15-9"F 7 $ Expiration Date: O/- 3/-o <br /> Date: 0 6- O r/-d 2- Contractor: We-s!- .44Pj�41- rIA4" ,.04 <br /> Signature, Title�jJrlio.+�t- <br /> I Printed name t crfAr�Jyµ.4y� <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the following declarations: (CHECK ALL THAT APPLY) <br /> _I have and will maintain a certificate of consent to self-insure for workers' compensation, as provided for by <br /> 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 policy numbers are: <br /> Carrier: /L•/11t-fit/-SArdIL4 Policy Number: 27- WS✓6/27 y/ <br /> i <br /> _JZcertify 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 a Labor Code. I shall <br /> forthwith comply with those provisions. /� / <br /> Date: Q 6 d`�D't- Signature• [.r • / <br /> Printed Name: 1-�rC6/7rri.d /7' r`�utAF� <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 /> 1er c11-17%-dA- `✓�s�-t'tM» (signature ofC-57 licensed authorized representative), <br /> hereby authorize(print name) dfr C7t(t• Vi 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 /> 5-17.20001 MI <br />