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EHU2DG1 671}011D <br /> VJEU PENrdI i APP <br /> San Joaquin County Environmental Health Department <br /> WELL&' BORING PERMIT APPLICATION SUPPLEMENTAL <br /> ,101`3 Ai)DRFSS: -4100 GWy LV\ � <br /> PERMIT SR# <br /> LICFNSLD CONTRACTORS DECLARATION (LCD) <br /> I hereby affirm that I ani licensed under the ptovssions of Chapter cJ(commencing with Section 7000) of <br /> LDivision 3 Of the Business and (professions Coder and my license is in full force and effect. <br /> Llcense#: _�� {j.� _ Exp Date: -1-3� .1 _ <br /> Date <br /> Signature-Ctsn ^L.2 MAA Title:_lellfQ <br /> Print Name:_Qnf%Q la <br /> WORKERS' COMPI=NSATION 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 <br /> provided for by Section 3700 of the Labor Code, for the performance of the work for which this <br /> permit is issued. <br /> _ I have and will maintain workers'compensation insurance, as required by Section 3700 of the <br /> Labor Code, for the performance of the work for which this permit is Issued. My workers' <br /> compensation insurance carrier and policy numbers are <br /> Carrier: z in, _ � _ Policy Numbcr:��}_i ll� �_ <br /> 14 <br /> 1 certify Neat in the performance of the work for whichh 111is permit is Issued, I shall not employ any <br /> person In any manner so as to become subject to the workers'compensation law of California, and <br /> agree that if I should become Subject to workers`compensation provisions of Section 3700 of the <br /> Labor Code, I shall forthwith comply with those provisions. <br /> Exp.pate:_ 4L7-1-tZ Signature:��srrl.� t 'L ti)(9ADA1,1r1A ri <br /> J <br /> WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVFRAGF IS UNLAWFUL,AND SHALL SUBJECT AN EMPLOYER Tr) <br /> CRIMINAL PFNAI.TIES AND CIVIL FINES 1,03 70$100,000,IN ADDITION TO THF COST OF COMPENSATION,INTEREST, <br /> ATTORNEY'S FEES,AND DAMAGES AS PROVIDED FOR IN SECTION 0706 OF THE LABOR CODE <br /> AUTHORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> 1, � .� �ri � u�-O�,d (siguature of C•57 licensed authorizeci representative), <br /> horohy aultlorize(prl i'i`/1df1o1 - <br /> IS_r] <br /> sign this San Joacli in County Well& tloring f erwit Allplic.ation on my behalf. I understand this authorization J <br /> Is valid for one year and Is limited to the work plan dated on the front page of this application. } <br /> 00 26 111 clrrscn;o %1-11 KR IT APP <br />