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San Joaquin County Environmental Health epartment Unit IV Well Permit Application Supplement <br /> JOB ADDRESS: OCOr"' PERMIT SR#: (�90 3 «l <br /> UCENSED CONTRAOTORS'DEOLARATION (LCD <br /> I hereby aft, that I am licensed under time provislons of ChaptQr 9 (commencing with teflon 7000)of Division <br /> 3 of the Business and Professions Cada and my licwae Is in W forca and effect. <br /> L1c�se#: U 'J ���-7 Expirallort date: l C) 3( .1 <br /> Date:_ CJl�: Contractor: ��c �,+ ✓� <br /> Signature: > -4-1 <br /> Printed name: Q- E �T� <br /> s <br /> WORKERS' CDMPENSATICN DECLARATION <br /> I hereby affirm under penally of perjury one of the following declarations: .(CHECK ALL THAT APPLY) <br /> _I have and will maintair, a certlticate of consent to ac!14mure.for workers' compenm atlan,as provided for.by <br /> Section 3700 of the Labor Cods,for the performance of isle work for whicri this permit is issued. <br /> r I have and w111 maintain workcrs' compensation insurancc, as requiisd by Section 3700 tithe Labcr Code, <br /> for Me perforrparlee of the work for whkh this permit is issued. My workers' compensation insurance ' <br /> carrier and policy numbers are <br /> Carrier. ,�� `� Qt)t-taC Palicy Nunmber. <br /> I azrilfy that in the perfom-mance of the work fcr which this permit is issued, I shall not employ any person in <br /> any manner sa as to become subject to time workers'compensation taws of Califomia, and agree that it I <br /> shnuld become subject to the workers'compensation provisions of Sermon 3700 of the Labor Cade.)shalt <br /> forthwith comply with those provisions. <br /> Data: Signatu v: ' <br /> Printed Name- <br /> WAMNG.FAILURE TO SECURE WQPJIZRS'COMPENSA-nOt1 COVERAGE IS UNLAWFUL,AND SHALL 3VEJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIVI ANA CnnL FINES UP TO ONE HL)NDRED THCV*AND DOLLARS <br /> ($100,000.),IN ADDITION TO THE COSTOF COMPENSATION,INTEREST,ATYt RNEY'S FEES.AND DAMAGES A5 <br /> PROViDED FOR 1N SECTION 3706 OF THE LABOR CODE <br /> �J t, UIJ CJ (C-57.11cansed authorized repretmntativeL hemby <br /> nereby authorize(print name) - <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 /> 1-25-02/MI <br />