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Are- <br /> 7 <br /> San Joaquin County Environmental Health Department Unit IV Well Permit Application Supplement <br /> JOB ADDRESS<2i5z-Eft&4' 1"ye-vtA rrt l i GjS'• PERMIT SR#:-O <br /> G}��tiGtL"('ovt, <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> I hereby affirm that l 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. ff <br /> L License#: C'5-2-7 11 S 10 Expiration Date: I _3I - 0 8 <br /> Date: 5 'C:3) - U bontraclor ' CC G(•e D1"j 11` �,If'l�r <br /> Signature: Ville: D�/ '�'`G`^nN�l <br /> Printed name: <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the following declarations: (CHECK ONE) <br /> _1 have and will maintain a certificate of consent to self-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: Policy Number^ L <br /> I certify that in the performance of the work for which this permit is issued, 1 shall not employ any person in <br /> any manner so as to become subject to the workers'compensation laws of California,and agree that'd I <br /> should become subject to the workers'compensation provision7Se n 3700 of the Labor Code,I shall <br /> forthwith comply with those provisions. <br /> Expiration Date: Signature: <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 /> ($100,000.),IN ADDITION TO THE COST OF COMPENSATION,INTEREST,ATTORNEY'S FEES,AND DAMAGES AS <br /> PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. <br /> �ORIZATJ0N-9QR QTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> (signature ofC57 licensed authorized representative), <br /> hereby authorize(print <br /> namo)^ 2y< �.('� �W(,(�'(� { GSE-•�'YI }3vt Cj(t/IVf)Ndf� l , <br /> to sign this San Joaquin County Well Permit Application on my bubo". 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 /> IiHU 2902i1U I <br /> 6R2e4 <br />