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I1V.��1 ✓CJU`I <br /> JI, I-:Ln- I I Ui :JJJ.'07G�JC1 <br /> I. <br /> II <br /> iI <br /> Napith Department Unit Iv Well Permit Application Supplemental <br /> SanJoaquin County Environmental <br /> li <br /> Jos ADDRESS: <br /> PERMIT SR# t� <br /> LICENSED CONTRACTORS DECLARATION LCD <br /> I hereby affirm that I am licensed under the provisions of Chapter 9(commencing with Section 7040)of <br /> Division 3 of the Business and Professions Code and my license is in full force and effect. <br /> Licsnse ' S-"7 7 —o 7 Exp Date: I3� ZOO <br /> Date: <br /> S o. Contractor. <br /> Signature: <br /> Title: 0��c� i <br /> Print Name sJh/ru <br /> WORKER`S COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the following declarationt:(check one) <br /> I <br /> 1 have and provided fu bly section 3700 l maintain a of the labor Code,cate of consent tfor the performance of the work foo sO-insure for workers' r which this <br /> Pr <br /> permit Is issued. <br /> I have and will maintain workers'compensation insurance,as required by Section 3700 of the <br /> Labor Code,for the performance of the work for whichthis permit is issued. My workers' <br /> compensation insurance carrier and policy numbers ere: <br /> Carrier. qL <br /> 0 C-1M -S Policy Number: G 00-? :3 63 <br /> I 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+he workers'compensation law of California,and <br /> agree that if I should become subject to workers'compensation pr 'sions of Section 3740 of the <br /> Labor l shall forthwith comply with those provision . <br /> Exp.Date: ora/—b j SigriaWre: <br /> Print Name: �•�< <br /> WARNING.FAILURE To SECURE WOROMM COUPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT AN EMPLOYER TO <br /> CRUdINAI.PFNALTIES AN6 CML FINES UP TO 5700,000.IN ADDITION TO THE COST OF COMPENSATION,INTEREST, <br /> ATTOREE <br /> NETS PS,AND DAMAGES ASP VInEO FOR IN SECTION 3708 OR THE LABOR C04P <br /> AUTHORIZATI O AN C-57 SIGNING PERMIT APPLICATION <br /> 1, Nis �� (slgnabure of C-57 licensed tathortrod representative), <br /> to <br /> hereby authorize(printl)re) . <br /> sign this San Joaquin county Well Permit Appiicatfon on my behalf. I understand this authorFratian is valid <br /> for one year and Is limited to the work pian dated on the front page of this application. <br /> ersaozrM <br /> WELL KPUM APP <br /> END 25-M WSW <br />