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San Joaquin County Environmental Health Department <br /> Unit IV Well Permit Application Supplement <br /> Job Address: .375 G✓esr 4111 ?To A7V-1 09 Permit SR#: <br /> 6206 <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 3 of <br /> the Business and Professions Code and my license is in full force and effect. <br /> License #: �`� �? - I ? Expiration Date: <br /> Contractor: Date: 6-Q- (3y <br /> Signature: UTitle: ( r' <br /> Print 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 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, for <br /> the performance of the work for which this permit is issued. My workers' compensation insurance carrier and <br /> policy numbers are: <br /> Carrier: A\(vSka Policy Number: OL4C-Lo S n <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 /> Signature: 2v L 1i i `�� Date: , - <br /> Print Name: `n o-y- Q <br /> Warning: Failure to secure workers'compensation coverage is unlawful,and shall subject an employer to criminal penalties and <br /> civil fines up to one hundred thousand dollars($100,000),in addition to the cost of compensation,interest,attorney fees, <br /> and damages as provided for in section 3706 of the Labor Code. <br /> AUTHORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> 1, zlvk" a-z� (signature of C-57 licensed authorized representative), <br /> herb� <br /> authorize (print name)_ lk3h Q�`�'!� , to sign this San Joaquin County <br /> Well Permit Application on my behalf. I understand this authorization is valid for one (1)year and is limited to the <br /> work plan dated on the front page of this application. <br /> EHD 29-02-001 WELL PERMIT SITE <br /> 8/27/2003 <br />