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Oct 01 2004 1 0: 46RM v i - •inex, inc 5`5687679 p. 2 <br /> San Joaquin County Environmental Health Department Unit IV Well Permit Application Supplement <br /> JOB ADDRESS:_ �U �p D l j,(�, PERMIT SR#: eU 4(1 ( ` 2- <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#: 10 5 go, Expiration Date: A, <br /> - 31— 00 <br /> Date: 10 1 — Contractor: Vt t2p p �C_ <br /> Signature: Title: <br /> r� <br /> Printed name: <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 /> Eby Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. <br /> _�! I have and will maintain workers'compensation insurance, as:requ.ired 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: � , Policy Numb'er-' COC 145 <br /> I certify that in the perforrriance of the work for which this permit is issued, I shall not employan <br /> y person in <br /> any manner so as to become subject to the workers'compensation laws of California, and agree that if <br /> should become subject to the workerscompensation provisions of Section 3700 of the Labor Code, I shall <br /> forthwith comply with those provisions. <br /> Expiration Al Signature: <br /> Date: <br /> Printed Name: <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 /> ($100,00,0.), IN ADDITION TO THE COST 01=COMPENSATION;;INTEREST,ATTORNEY'S FEES, AND DAMAGES A$ <br /> PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. <br /> AUTHORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> 1, (signature of C-57 licensed authorized representative), <br /> hereby a h raze(print name) <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 /> 3-19-03/MI <br /> s.Li1fr.'ii{'a5. ,a' t .Y3'f1n4k:E .kfi6kv+i!,N,...+:, <br />