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Recei,..:ed: 5/12/07 13:56; 2094663433 -> HR LaserJet 3100; Page 2 <br /> 12/05/2007 WED 12: 15 FAX 20946 33 SJC END 0002/002 <br /> San Joaquin County Environmental Health Department Unit IV Well Permit Application Supplement <br /> JOB ADDRESS: .- I -c c> PERMIT 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 Division <br /> 3 of the Business and Professions Code and my license is in full force and effect. <br /> License#: X20 —Exxpi_ration Date: D U g <br /> Date: [�'I �Ia Contractor: P4J��' <br /> Title: CI ©/���c►1��1� Meow, <br /> Signature: --7- <br /> Printed name: <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 /> I by Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. <br /> 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: IZ1J <br /> r .1164 <br /> Carrier: 7�q �o,npr�sc•1 1-� a 4'a-Policy Number: <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, I shall <br /> forthwith comply with those provisions. <br /> Expiration Date: Signature: <br /> Printed Name: <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 /> AUTHORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> IW �� (signature ofC-57 licensed authorized representative), <br /> hereby authorize(print name) wet - mW41 CHEF <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 /> 8-29-02 1 MI <br /> 1-.1I1)29.02.001 <br /> 6/22/04 <br /> 1./ 1. abed `8t,:01. LO-380-L `•04TnS4af`•OOtC 4ap.lase-1 dH :A9 1u86 <br />