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02/22/20os 09: 10 FAX 4" euc <br /> San Joaquin County Epvironmental Health Department Unit tv Well Permit Application supplement <br /> ItIN , 1954 Flmp Ave • PERMIT SR#: 7/ 7 ,J/ <br /> JOB ADDRESS: Gl T^t s'a 9s-2e 3 <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> I hereby affirm that I am licensed under the provisions of Chapter 9(commencing with Section 7000) of Division <br /> 3 of the Business and Professions Code and my license is in full force and effect. <br /> ^z—3� Expiration Date: <br /> LicensciR <br /> zz o Contractor. <br /> Date: - <br /> Signature: « Title: <br /> – / <br /> Print name• � <br /> �( u •'^ <br /> WORKERS' COMPENSATION DECLARATION <br /> 1 hereby affirm under penalty of perjury one of the following declarations: (CHECK ONE) <br /> I have and will maintain a certificate of consent to aelf-insure 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 Labor Code, <br /> for the performance of the work for which this permit is issued. My workers' compensation insurance <br /> carrier and policy numbers are: <br /> Carrier: _lam- l ✓� Policy Number. <br /> 1 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 if 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: l J/ 1 Signatures <br /> Printed Name: <br /> WARNING: FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> ($100,U00.).IN ADDITION TO <br /> FTHE OF LABOR COMPENSATION,INTEREST,ATTORNEY'S FEES,AND DAMAGES AS <br /> PROVIDED FOR N SECTION <br /> A HOR17ATION OTHER <br /> THAN C-57 SIGNING PERMIT APPLICATION <br /> �TG.—. (signature ofC-67 licensed authorized representative), <br /> hereby au Drize(print nems) L i <br /> to sign this San Joaquin County Well Permit Application on my behalf. 1 understand this authorization Is valid for <br /> one(1)year and Is limited to the work plan dated on the front page of this application- <br /> 8-29-021 MI <br /> EHD 29-02.001 <br /> /JiJlM <br /> a d Baia-ess CDCs) 2U? tf > Ja ISN dso :al 90 as pact <br />