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San Joaquin County Environmental Health Department Unit IV Well Permit Application Supplement <br /> JOB ADDRESS.2i52-60 0" 1 re vin frtn F PERMIT SRM 00 <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 /> License#: C S D——11--' S 1 Expiration Date: 1 -31 - 08 <br /> Date: 5 - U b ontractor: a a 5 co'd e D riIi iyleq, <br /> Signature: T tle: D�y• M'�� <br /> Printed name: �PM , <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the following declarations: (CHECK ONE) <br /> _I 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: �7 1�` 1V 1 i K�^ Policy Number: WS �)OSaJ I <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 Se n 3700 of the Labor Code, I shall <br /> forthwith comply with those <br /> -rprovisions. <br /> Expiration Date: 57- 1 —� t 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 /> �ORiZAiiJAN-&QR�.�.._THAN C-57 SIGNING PERMIT APPLICATION <br /> L r, �j (signature ofC.67 licensed authorized representative). <br /> hereby authorize(print nameLjgl ct Llfy0,4rQEI <br /> , <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 /> 8.29.02/MI <br /> MID 29.112-0U 1 <br /> rrn" <br />