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l� <br /> s <br /> f <br /> San Joaquin County Environmental Health Department Unit IV Well Permit Application Supplemental <br /> JOB ADDRESS: PERMIT # D7�L <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> I <br /> I hereby affirm that I am licensed under the provisions of Chapter 9 (commencing with Section 7000)of j <br /> Division 3 of the Business and Professions Code and my license is in full force and effect. i <br /> License#: -U' I'�/� Exp Date: 112-010 <br /> Date: �h Contractor: GrMqYII19 li) TPS l�L <br /> (Signature t'% Title: Iv�G-n�1� <br /> Print Name: ChviS,gw l\O-A' �4VA'IeV- <br /> WORKER'S 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 <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 /> j Labor Code, for the performance of the work for which this permit is issued. My workers' <br /> i <br /> compensation insurance carrier and policy numbers are: <br /> Carrier: J 11��fi Policy Number: 53/0V0D-U <br /> I certify that in the performance of the work for which this 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 provision of Section 3700 of the <br /> Labor Code,, I shall forthwith comply with those provis' s <br /> Exp. Date: I' f U� I Mgnatur <br /> Print Name: <br /> WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT AN EMPLOYER TO <br /> CRIMINAL PENALTIES AND CIVIL FINES UP TO$100,000,IN ADDITION TO THE COST OF COMPENSATION,INTEREST, <br /> ATTORNEY'S FEES,AND DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. <br /> OR ON F OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> I, (si ture of C-57 licensed authorized representative), <br /> hereby aut orize(print name) ,to <br /> sign this San Joaquin county Well Permit App tion on my behalf. I understand this authorization is valid <br /> for one year and is limited to the work plan dated on the front page of this application. <br /> 8/29102/MI <br /> EHD 29-01 11/5107 WELL PERMIT APP <br />