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r�4 <br /> San Joaquin County Environmental Health Department Jnit IV Well Permit Application Supplemental <br /> JOB ADDRESS: b ( 9 L (� �"0 PERMIT SR # I 6 � <br /> LICENSED CONTRACTORS DECLARATION ( LCD ) <br /> I hereby affirm that I am licensed under the provisions of C iapter 9 (commencing with Section 7000) of <br /> Division 3 of the Business and Professions Code and my Ii tense is in full force and effect . <br /> License #: :xp Date : <br /> Date: pq h Contractor: _ <br /> Signature: Title: _ <br /> Print Name( <br /> WORKER'S COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the followinc declarations: (check one) <br /> I have and will maintain a certificate of consent to ; elf-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 im urance, 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: 1 ' _ ' 1 \� ., Policy Num Ser: ( <br /> I certify that in the performance of the work for whi :h this permit is issued , I shall not employ any <br /> person in any manner so as to become subject to a he workers' compensation law of California , and <br /> agree that if I should become subject to workers' c )mpensation provisions of Section 3700 of the <br /> Labor Code , I shall forthwith comply with those prc visions. <br /> Exp. Date : Signature: , <br /> Print Name : <br /> WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAG E IS UNLAWFUL, AND SHALL SUBJECT AN EMPLOYER TO <br /> CRIMINAL PENALTIES AND CIVIL FINES UP TO $100,000, IN Al IDITION TO THE COST OF COMPENSATION, INTEREST, <br /> ATTORNEY'S FEES, AND DAMAGES AS PROVIDED FOR IN SE ;TION 3706 OF THE LABOR CODE . <br /> AUTHORIZATION FOR OTHER THAN C-5" SIGNING PERMIT APPLICATION <br /> I, (signature of C-57 licensed authorized representative), <br /> hereby authorize (print name) Advanced GeoEnvir nmenfal Rep e enLaL ive /Ally Coiavita to <br /> sign this San Joaquin county Well Permit Application on mi ' behalf. I understand this authorization is valid <br /> for one year and is limited to the work plan dated on the fro it page of this application. <br /> 81291021MI <br /> EHD 2941 111WT WELL PERMIT APP <br /> Y <br />