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San Joaquin County nvironm�eyntal Health De artment Unit IV Well Permit Application Supplement <br /> JOB ADDRESS: <" / N• PERMIT SR#: a)e �� 3 <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#: 6 j3��S 7 _Expiration Date: d I 1� I I 1 p 0 0 s <br /> Date: ��10&W 00 Contractor: <br /> Signature: Title: Gpi Prag�0.V '^`t" <br /> Printed name: `S A,[�o': �A-LLA<,RE7(Z <br /> 5 <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 /> b1i Section 3700 of the Labor Code,for the performance of the work for which this permit is issued. <br /> -N!J 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: L l i3t-r7 �`i fVk TV �L Policy Number: 7 <br /> I certify that in the performance of the work for which this permit is issued, I,shall not employ any person in <br /> a.-iy 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.c� <br /> Expiration Date: 3C O Signature: <br /> Printed Name: �i4c0 � G Nil? <br /> WAR14ING: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 /> (S1oo,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 /> I _ - A I (signature ofC-57 licensed authorized representative}, <br /> A <br /> hereby authorize(print name) x IN o s- 4 ,2 <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 /> 8-28.021 MI <br /> EHD 29-02-001 <br /> 6122/04 <br /> Z8/ZO 3Etid DNI-IdWVS NOISIE1366 hLSbLEZOTS LZ:LT L00Z/9T/L0 <br />