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San Joaquin County Enviroh",iental Health Department Unit IV Well Permit Application Supplemental <br /> JOB ADDRESS: k' � , � af CA <br /> PERMIT 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 the Business and Professions Code and my license is in full force and effect. <br /> License* 1 (00-4 Earp Date: 62 3 (- <br /> Date: - Z 6-Q J Contractor: W6))p 1-12: JL.�IL,u,�rCo MJ66L\( <br /> Signature: �aar��t c _(t�,nr / r .t f Title: pp. sI Qe�Nr <br /> 47 <br /> Print Name: t'_omCfn/(s __ l o0wM <br /> WORKER'S COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the following declarations: (check ane) <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 /> 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: <br /> Carrier: $mne Fuly t� Policy Number: <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 l should become subject to workers' compensation provisions of Section 3700 of the <br /> Labor Code, I shall forthwith comply with those provisions. <br /> Earp. Date: ! O - ?.v 0 9 Signature: _l: ' 6. t, . <br /> Print Name: G°Ntnr _G VudoQ .,? <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 /> 1, �AUTHOR ZATI N FOR OT R THAN C-57 SIGNING PERMIT APPLICATION <br /> � " '? (signature of C-57 licensed authorized representative), <br /> hereby authorize (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 /> W29i02100111 <br /> E1102"i IMAT WELL PF14MIT APP <br />