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San Joaquin County Environmental Health' Department Unit IV Well Permit Application Supplemental <br /> JOB ADDRESS : 130 N . Nl4NTEiZST, 7tock �`V.l C4PERM1T SR # <br /> LICENSED CONTRACTORS DECLARATION ( LCD ) <br /> I <br /> I hereby affim that I am licensed under the provisions of Chapter 9 ( commencing with Section 7000) of <br /> Division 3 of the Business acrd Professions Code and my license Is In full force and effect <br /> License p to 3 (P 3 g 7 _ <br /> _ [ <p0ate 131 7-010 <br /> Date q 7v OC) - Contractor —EKE gsIUrJ Sl� MPLr_ t16 1 � JG . <br /> Signature - Title L0C.I�-TJpti1 MRkIq{� t7t <br /> I Print Name GgE►JjI ( kAVw/Ei2Ab <br /> WORKER'S COMPENSATION DECLARATION <br /> I herebv affirm under penalty of perjury one of the following declarations (check one ) <br /> I nave and will maintain a certificate of consent to self-insure for workers' compensation . as <br /> provided for by section 3 '00 of the labor Code , for the performance of the work for which, this <br /> permit is Issued <br /> �_. I have and will maintain workerscompensation 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 eno policy numbers are <br /> PrMEAIC-ASI 1rJTEAt.rtA-71AvgL <br /> Carrier : SPELtALTLt L. IAJeS Policy Number. C_ p 3t-} Z_4i Liz ( C r ) <br /> I INSvLAwJ .. C��� i <br /> ! 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' rompensation provisions of Section 3700 of the <br /> i. abor Code . I shall forthwith comply with those proj�isinns f <br /> Exp . Date Io �, 3U � ZUjG Signature : <br /> Print Name : -612Er-jDA CKJD1W''F-0g1) <br /> WARNING FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO <br /> CRIMINAL PENAL TIES AND CIVIL FINES UP TO 3100, 000. IN AODmON TO THE COST OF COMPENSATION, INTEREST <br /> AT' ORNEY 5 FEES, AND DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE <br /> U }i zATION FOR OTHER THAN C -57 SIGNING PERMIT APPLICATION <br /> (signature <br /> �of�C ,57 licentsed authorized representative 1 , <br /> hereby authorize (print name) 7a ? I� <br /> � � W 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 />