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San Joaquin County Environmental Health Department Unit IV Well Permit Application Supplemental <br /> vPk <br /> Q—s toc } - <br /> on lard, , aha'-'luck- Ck <br /> JOB ADDRESS: Cpeck- i 1igAw6o.!Z DnUQ- , SfMU4�ERMIT SR# <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> I hereby affirm that I am licensed under the provisions of Chapter 9 (commencing with Section 7000) of <br /> Division 3 of theBusinessand Professions Code and my license is in full force and effect. <br /> � 7 <br /> License#: I0'5g2-� Exp Date: OSI�Jt/ 2-009 <br /> Date: N - OH D3 Contractor: 7�� J1 'conte <br /> Signature: Q Ctck Title: Nf)Ce <br /> Print Name: ck <br /> WORKER'S COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the following declarations: (check one) <br /> XI 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 /> I 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: ll <br /> Carrier: IE) sa Policy Number: d aL I <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, I shall forthwith comply with those provisions. per,I (� , a <br /> Exp. Date: <yR Signature: ���wa Gly <br /> Print Name: - forncer�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 /> UTHORIZPyT�ON FOR QTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> I, ,l fou Q L L CUtA::,��,, /� (signature of C-57 licensed authorized representative), <br /> hereby authoriz (print name) 1 �,1Ne,02 \ GLS' kn- Q ; i QJ c kcod 1-� ( Q S , 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 /> R/291021MI <br /> EHE 29-01 1115107 WELL PERMIT APP <br />