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OCT 02 2003 4: 01PM HP LASERJET 3200 p. 2 <br /> San Joaquin County Environmental Health Services,Unit IV ftil Permit Application Supplement <br /> JOB ADDRESS; ��� /�CtPST �c � PERMIT SR#: <br /> ox-? x CA,— <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 Ilcense is in full force and effect. <br /> License clU 7 Expiration Date: !d�37 d, <br /> Date: 1�1�7 CS'� Contrac 2K <br /> Signature: Title: cZ � <br /> Printed name:, <br /> WORKERS' COMPENSATION DECLARATION <br /> I 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 /> _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: <br /> Carrier:— (37 c5�'j� Policy Number: Z,4 E.L. C ! d a-% 7 <br /> `tet 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! <br /> should become subject to the workers' compensation provisions of Section 3700 of ' e Labor Code, I shall ' <br /> forthwith comply llwith those provisions. <br /> Date: C�/�'/ ems? Signature: <br /> Printed Name: L_. <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 /> 1. <br /> (signature ofC-57 licensed authorized representative), <br /> hereby authori a(print name of - S <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 /> 5-17-2000!MI <br />