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04 -01 02: 14 UR - InK ENV I R DEPT 51 '43268 to . 2 <br /> .LU# •3i1 s.e+u'3 1/'aes jbygl �3 FIFTH FLOOR <br /> PAGE 83 <br /> San Joaquin County Environmental Health Departmerht Unit IV Well Permit Application Supplement <br /> JOB ADDRESS: PERMIT SR#: <br /> LICENSED CONTRACTORS DECLAMATION (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 /> License#: C67 742.0 13 Expiratfon Date: <br /> Date: I Contras I`(/( s <br /> Signature: -80�z_ Title; �d ly(G12�' <br /> r ,� r <br /> Printed name: (�;Fm fa 2Vt rw. <br /> WORKERS' COMPENSATION DECLARATION <br /> 1 hereby affirm under penalty of perjury one of the following declarations: (CHECK ALL THAT APPLY) <br /> I have and will malntain a certificate of consent to self-Insure for workers'cempensatien, as provioed for by <br /> ZIection 3700 of the Labor Code,far the performance of the work for which this permit is Issued, <br /> have and will maintaln workers' compensation insurance, as required by Section 3700 of the L,nor Cone, <br /> for the performance of the work for which this permit Is issued, My workers' compensation insuranoe <br /> carrier and policy numbers are: <br /> Carrier: I—Iar1 AAVlq(,_Ttar (fig c Policy Number: <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 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 /> Date: 3 n> Signature: Zuea <br /> i- <br /> Printed Name: ei`'w►- <br /> WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL,AND $HALL SUBJECT <br /> AN]EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TD ONE HUNDRED THOUSAND DOLLARS <br /> (5100,000.),IN ADDITION TO THE COST OF COMPENSATION,INTEREST,ATTORNEY'S FEES,AND DAMAGES AS <br /> PROVIDED pOR IN SECTION 3T06 OF THE LABOR CODE. <br /> d��L <br /> I, &au _ (signature ofC37licensed authorized representative), <br /> hereby authorize(print name) ellQ9,1191AEN Et'C-,- <br /> to sign this San Joaquin County Well permit Applicatlon 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 /> 1.25.021 MI <br /> T/T 'd 06T 'ON S006-E06 (29S) o,,l5ld WdTO:T E002'E 'SON <br />