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02/22/2005 10:43 916862b;"31� sEcc)R PAGE 02/02 <br /> San Joaquin County Environmental Health Department Unit IV Well Perm It Application Su I me <br /> A,1d Rim i4..-A� •�f�7��1 <br /> JOB ADDRESS: a3 c ..,��,c til, .,r PERMIT <br /> O'wK"'y <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 scensd is in full force and effect. <br /> License #: C-n7 -7 (-05&YO Expiration Date: <br /> Date: . 6:! Contractor;6nf4el��lr'f `rr•�7�1C ' <br /> Signature: Titleati7�`rd/�1 fYg�c�P <br /> Printed name <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the following declarations: (CHECK ONE) <br /> _I have and will maintain a certifioate of consent to sslf-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 i5 issued. <br /> 1 have and will maintain workers' compansation insurance,as required by Section 3700 of the Labor Code, <br /> for the performance of tha work far which this permit is issued. My workers' compensation insurance <br /> carrier and policy numbers are: <br /> Carrier: seo&,rphi Policy Number: ix fQ `k d z3c( <br /> t <br /> 1 certify 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 subjvrt to the workers'compensation provisions of Section 3700 of the Lat or Code, I shall <br /> forthwith comply with those provisions. <br /> Expiration Date: ignature <br /> /Printed Name: <br /> ,wi o� <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.),1N APOITION TO THE COST OF COMPENSATION,INTEREST,ATTORNEY'S FEES,AND DAftiMAQES AS <br /> PROVIDED FOR IN SECTION 3?0 OF TKE LABOR CODE. <br /> AUTHORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> I, P (signature ofC•57 11censed authorfxed representative), <br /> hereby authorize(print name)-D0.r.p+� 56e0't`� �, (,e�MalCo�dil <br /> to sign this San Joaquin County Well Permit Application on my behalf_ I understand this authorization In volid for <br /> one(i)year and Is limtted to the work plan dated on the front page of this application. <br /> 8-29-02/MI <br /> END 29.02.001 <br /> 6/22/(14 <br /> Z© 39VJ JNI-171I IG 993�i9 Z©E©ET65Z6 es:01 902Z/ZZ/Z0 <br />