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San Joaquin County Environmental Health Department Unit IV Well Permit Application Supplemental <br /> JOB ADDRESS: 2tf � PERMIT SR# 05 <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> I hereby affirm that I am licensed under the provisions of ChapterT (corrimencing'wi)h'Section 7000)of <br /> Division 3 of the Business and Professions Code and my license is in full force and effect. <br /> i <br /> License#: ✓r 1 Exp Date: 3 12-01 �-- <br /> Date: �2 v Contractor: r I�I ( 1 et Y_ - <br /> Signature: Title: <br /> Print Name: hrlS 11V ?KV1'e V' <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 /> X— 1 have and will maintain workers'compensation insurance, as required by Section 3700 of the <br /> Labor Code, for the performance of the work for which this permit is issued. My workers' <br /> compensation insurance carrier and policy numbers are: <br /> Carrier: SPY — Policy Number: 7����6��� — <br /> I certify that in the performance of the work for which this permit is issued, I shall not employ any <br /> person in any manner so as to become subject to the workers' compensation law of California, and <br /> agree that if I should become subject to workers' compensation provisions of Section 3700 of the <br /> Labor Code, 1 shall forthwith comply with those provisions. <br /> Exp. Date: 0 0 09 Signature: <br /> Print Name: CMOOetlU�1�IP,t� <br /> WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT AN EMPLOYER TO <br /> CRIMINAL PENALTIES AND CIVIL FINES UP TO$100,000,IN ADDITION TO THE COST OF COMPENSATION,INTEREST, <br /> ATTORNEY'S FEES,AND DAMAGES AS PROVIDED FOR IN SECTION 3706 OF,THE LABOR CODE. <br /> 19 A_ ATIaFQR_OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> I, (signatur of C-57 licensed authorized representative), <br /> hereby authol Ize(print name) ,to <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 /> 8129f021MI <br /> EHD 2&01 11/5107 WELL PERMIT APP <br />