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San Joaquin County Environmental Health Department Unit iV Well.Permit AppllcationSupplement <br /> JOS ADDRESS:^ ' PERMIT SR#: I <br /> i <br /> LICENSED CONTRACTORS DECLARATION WC-D) <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#: E36387— ExpirationDate: 1 131120 r0 <br /> Date: Contractor, Precision Sampling, Inc. <br /> Sinature ____Tit{e: X.ocation. Manacfez- <br /> 9 i <br /> s <br /> Printed name: BrQnda. Ctawfordi — <br /> I <br /> WORKERS'COOMPENSATiON DECLARATiON <br /> i <br /> 1 hereby affirm under penalty of perjury one of the following declarations: (CHECK.ONE) <br /> 1 have and will maintain a certificate of consent to.salf 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 /> I <br /> 1 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 permitis issued. My workers'compensation insurance <br /> carrier and policy numbers are: <br /> l ' <br /> Carrier 3,iberty Mut g&1 ZnSu_r_gnce_ Policy Number:WC1 AJ107233 9 027 <br /> i <br /> I cartify 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 l i <br /> should become subject to the workers'compensation provisions of Section$700 of the tabor Code,;I shall <br /> forthwith comply with those provisions. <br /> Expiration Cate: 6 22L20b8 Signature: l <br /> Printed Name: Brenda Crawford <br /> WARNiNGi FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE 1$UNLAWFUL,AND SHALL SUBJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FiNES UP TO ONE HUNDRED THOUSAND DOW-ARS($104,000.),IN ADi]IT(0N TO THE COST i0F COMPENSATION,INTEREST,.ArroRNEY'S FEES,AND DAMAGES AS j <br /> PROVIDED FOR IN SECTION 3706 Ot=THE LA19OR'CODE, <br /> AUTHORiZATION FOR.QTHAN C-67 SIGNING PERMIT APPLICATION � l <br /> � �; _- -�^^•"" `� (signature afc-67 IiGensed authorized representative), { <br /> ,^ <br /> herebysuthwize(print-name) 0ew1 `i j <br /> to sign this SanJoaquinCounty Well Permit Application on my behalf.i understand this authorization Is valid for i. <br /> one(1)year and is limited:1b the work plan dated on the front page of this application. 1 <br /> DO 29-02.001 <br /> 6/22104 <br /> { I <br /> i <br /> i <br /> I <br />