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-�2uc•/—� 5, F � r Q <br /> San Joaquin County Environmental Health Department Unit IV Well Permit Application Supplement <br /> JOB ADDRESS: IZV 6y PERMIT SR#: eO5 6 a ,) <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> 1 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#: 2 O Expiration Date: ` 36- 0 S <br /> Date: ' . 2 d07 Contractor. DC 4- (C (II (�� <br /> Signatur Title: gttj (nfte1-LST ms oo <br /> Printed name: kin �60 ✓� <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 /> by Section 3700 of the Labor Code,for the performance of the work for which this permit is issued. <br /> Qy I 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 /> /� �� pc mtbe ) ��r'6g7S6S-b( <br /> Carrier:�'j &eej h"ll� &" / Policy Number: <br /> I certify that in the performance of the work for which this pennd 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 1 <br /> should become subject to the workers'compensation provisions of Section 3700 of e L bor Code, I shall <br /> forthwith comply with those provisions. <br /> Expiration Date: Di ©Qj Signature: i , <br /> Printed Name: Y\e1 n ett-L Cook <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 R O THAN C-57 SIGNING PERMIT APPLICATION <br /> I, (signature ofC-57 licensed authorized representative), <br /> p I <br /> hereby authorize(print name) '�I), f Q.Y1-1 �Q�Z�I X-7 - <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 /> EHD 29-02-001 <br /> 6P22/04 <br />