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San Joaquin County inviron�m-e"ntal Health Department Unit IV Well Permit Application Supplement <br /> JOB ADDRESS: o-.� 0� r,rf5 fY��"'��" s PERMIT SR#. 00V0102, <br /> 0 �1616 5 <br /> LICENSED CONTRACTORS I� TORS DECLARATION, (LCD) <br /> I hereby affirm that I am licensed under the provisions of Chapter 9 (commencing wit Section 7000) of Division <br /> 3 of the Business and Professions Code and my license is in full force and eff ct. <br /> i // <br /> License#: 4 Expiration DAAater (1` a� <br /> Date: Contrac / •/ 0 <br /> Signature: ! Title: <br /> Printed name: <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 q <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: I <br /> f1 Q/A <br /> Carrier: I r / /f� vVt`� N w"a�ifl7l y Policy Number: MY 0 W <br /> I certify that in the performance sof the work for which this permit is issued, I shalt 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 .. kf <br /> forthwith comply with those provisions.,, <br /> l� <br /> 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 /> AUTHO IZATION FOR OTHERiTHAN C-57 SIGNING PERMIT APPLICATION <br /> I, Wqf / !i ��1 (signNature ofC-57 licensed authorized representative),' <br /> 0 S � lfDf7 �0�t1 �^�i�rnnme.U�i-1 . . <br /> hereby authorize(print name) R'ex �� <br /> p fj <br /> ' to sign this San Joaquin County WellI Permit Application on my behalf. I understand this authorization is valid for <br /> I <br /> one (1)year and is limited to the work plan datedon the front page of this application. <br /> 8-29-02 1 MI <br />