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FSanJoaquin County Environmental Health DeDartment Unit IV Well Permit Application Supplement <br /> ADDRESS: PERMIT SR#: <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> 1 hereby affirm that I am licensed under the provisions of Chi pter 9(commencing with Section 7000)of Division <br /> 3 of the Business <br /> ((and <br /> 2Professions Code and my license is in full force and effect. <br /> License 9:r7 1'1 JC l� Expiration Date: <br /> Date: C1 _ ontractor.'E1IMLI <br /> Flgnatur ....... Title:-- <br /> Printed name: <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the following ceciarations: (CHECK ONE) <br /> I have and will maintain a certificate of consent to self-insurs for workers'compensation,as provided for <br /> _.._by 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 tabor Code, <br /> for the performance of the work for which this permit is it sued. My workers'compensation insurance <br /> carrier and policy numbers are: b 1 <br /> Carrier.� o_�._Polic;~!Number: I�l I V <br /> I 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 K I <br /> should become subject to the workers'compensation provisions of Section 3700 of the Labor Code, I shall <br /> forthwith comply with those provisions. <br /> Expiration Date: Signature• '' ��� <br /> Printed �8: '�� <br /> WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UV TO ONE HUNDRED THOUSAND DOLLARS <br /> ($100,000.),IN ADDITION TO THE COST OF COMPENSATION,14TEREST,ATTORNEY'S FEES,AND DAMAGES AS <br /> PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. <br /> AUTH TION F R OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> 1 <br /> ftt`g�nature ofC-57 licensed authorized representative), <br /> hereby authorize(print name) 1 <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 p ge of this application. <br /> 8-2942/MI <br /> EHD 24-02-001 <br /> 61VO4 <br />