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06/01/2007 FRI 11:31 FAX Q002 <br /> San Joaquin County Environmental Health peps --nt Unit IV Well Permit Application Supplement <br /> JOB ADDRESS:C, )F100( LCX7 1PERMIT SR#: <br /> LICENSED CONTRACTORS DECLARATIONL( CDf <br /> I hereby affirm that I am licensed under the provisions of Chapter 9(commencing with Section 7000)of Division <br /> 3 of the Businte's�s and Professi ns Code and my license is in full force and a . <br /> License#: 1 lJ� Expiration`Date: <br /> Date. Co otor J ',LJ vi <br /> Signature: II Title: -!l <br /> Printed name: 2k �� C , I cl� (� <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 self4risure 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 /> 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 permit is issued. My workers'Compensation insurance <br /> carrier andpolicynumbers are: <br /> Carrier. �/ �-" Fij n t Policy Number: <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 /> Expiration Date: Signature: <br /> Printed Name• ZI'Jc.y'-+ llr <br /> WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVE tAOE IS UNLAWFIl AND SMALL SUBJECT <br /> AN EMPLOYER To CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> ($700,000.),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 /> AUTf ORIZATION FQR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> I, L/ (slgnature*M47 lice authorized representative). <br /> hereby authorize(print name) <br /> to sign this San Joaquin County Well Permit Application on my behalf, 1 understand this authorization is valid for <br /> one(1)year and Is limited to the work plan dated an the front page of this application. <br /> 8-211412 1 Ml <br /> E!ID 29-w-W i <br /> 45114IM2 <br />