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Jun 20 05 04o15p Gr= g Drilling 925 30302- p. l <br /> -- -- —�-- - -- - <br /> San Joaquin County vironmental Health <br /> /Department Unit IV Well Permit Application Supplement <br /> JOB ADDRESS: /1� PERMIT SR#: y <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#: y 5 i 01 Expiration Date: J 1 0d 1 lo CP <br /> Date: lY(7 A t7 5 Contractor: X01 !A'L JL:1ZL <br /> Signature: 1� "-' Title: <br /> Printed name: (((////l h �O L4 WO U k-K-- <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 /> -4�dhave 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 /> carder and policy numbers are: <br /> Carrier: by-:( int Policy Number: I D4"(o( <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 tabor Code, I shall <br /> forthwith comply with those provisions. <br /> Expiration Date: b &ignature: <br /> Printed Name:,--�A <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 /> AUTHORIZAT\IONd FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> ,,-I (signature ofC-57 licensed authorized representat(ve), <br /> hereby authorize(print name) O) <br /> to sign this San Joaquin County Well Permit Application on my behalf. I u Pdorstand 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 /> 6-2M21 MI <br /> EHD 29-02-001 <br /> 622/04 <br />