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Z ;51 7 sV <br /> San Joaquin County Environmental Health Department Unit IV Well Permit Application Supplemental <br /> JOB ADDRESS: JUL .C�r�}L`�,��1.,Gw C�i PERMIT SR# V2 7 <br /> 1%)6 <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> I hereby affirm that I am licensed under the provisions of Chapter 9 (commencing with Section 7000)of <br /> Division 3 of the Business and Professions Code and my license is in full force and effect. <br /> License#: 7110 01 a Exp Date: 0-11-S69 <br /> Date: 1 y I O s Contractor:w A a b �d C'r <br /> Signature: cgmreI� G. &107' Title: 'PP.t5S'/2CAI! <br /> Print Name: t oAfCtAWGr G, UlfiDDWAR� <br /> WORKER'S 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 <br /> provided for by section 3700 of the labor Code,for the performance of the work for which this <br /> permit is issued. <br /> I have and will maintain workers' compensation insurance, as required by Section 3700 of the <br /> Labor Code,for the performance of the work for which this permit is issued. My workers' <br /> compensation insurance carrier and policy numbers are: <br /> Carrier: STAITE RVA/D Policy Number: OW- 002-02-38 <br /> I certify that in the performance of the work for which this permit is issued, I shall not employ any <br /> person in any manner so as to become subject to the workers' compensation law of California,and <br /> agree that if I should become subject to workers'compensation provisions of Section 3700 of the <br /> Labor Code, I shall forthwith comply with those provisions. <br /> Exp. Date: 10 - ZoOq Signature: �tG � �t/b'dDvwai�0[ <br /> Print Name: CaArCfAf& 9: W6-6OW#1eD <br /> WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT AN EMPLOYER TO <br /> CRIMINAL PENALTIES AND CIVIL FINES UP TO$100,000,IN ADDITION TO THE COST OF COMPENSATION,INTEREST, <br /> ATTORNEY'S FEES,AND DAMAGES AS PROVIDED FOR IN SECTION 37000F THE LABOR CODE. <br /> � ylLAUTHORI TI N FOR OT ER THAN C-57 SIGNING PERMIT APPLICATION <br /> I, eyl)cyA (�ir�aGArAA (signature of C-57 licensed aukiorized representative), <br /> hereby authorize(print name) S:.,r r"J l� ���p� i �tc 1�� S U' gr�an� to <br /> sign this San Joaquin county Well Permit Application on my behalf. I understand this authorization Is valid <br /> for one year and is limited to the work plan dated on the front page of this application. <br /> 8129/02MI <br /> EHD2 l 115107 WELLP RWT AW <br />