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San Joaquin County E iroriZ�, <br /> ealtn rvices,Unit lir Well Fie R Applicalion Supplement <br /> JOB ADDRESS: �CPERMIT SR#- <br /> LICENSED CONTRACTORS DECLARATION (LCD <br /> I hereby affirm that i am licensed under the provisions of Chapter 9(commencing with Section 7000)of t)ivision <br /> 3 of the Business anti Professions Code and my license is in full force and effect. <br /> License df: Expiration Date: 3 Z&j 1-4D v 3 <br /> Dale: /c/ Contractor: <br /> Signature: ��il�r��J Title:�� J <br /> Primed name: ' l / .41C&)gJ <br /> WORKERS' COMPENSATION DECLARATION <br /> 1 hereby affirm under penalty of perjury one of the following declarations: (CHECK ALL.THAT APPLY) <br /> I have and will maintain a Certificate of consent to self-insure for workers'compensation,as provided for by <br /> _._.Section 3700 of the Labor Code,for the performance of the work for which this permit is issued, <br /> bbl have and will maintain workers'compensation insurance,as required by Section 3700 of the labor Come, <br /> for the performance of the work for which this permit is issued. My workers'compensation insurance <br /> carrier and policy numbers are: <br /> Cannier, 1 f rM:—Policy Number:154-3 7 V -4) / <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 Labor Code, 1 shall <br /> forthwith comply with those provisions. <br /> Date: Signature: '— <br /> Printed Mama, <br /> WARNING- FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWPUL,AND SMALL SUBJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> ($100,000.),IN ADDITION TO T"E COST Of COMPENSATION,INTEREST,ATTORNEY'S FEES,AND DAMAGES AS <br /> PROVIDED FOR IN SECT/ION 3706 OF THE LA13OR CODE. <br /> I, "�� //��-'('�,./l✓ (C/57 licensed authorized representative),hereby <br /> authorizesS rrI"r� ��iE,'x Cal�.Sv��Asti� �n <br /> r <br /> to sign this San Joaquin County Well Permit Application on my behalf. I 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 /> S-77-20001 NII t <br /> Z 'd eGE :01 10 90 JeW <br />