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San Joaquin County Environmental Health Department Unit IV Well Permit Application Supplemental <br /> JOB ADDRESS: 34CO 1 viLt �kLpCA t[ ��I OPERMIT SR # <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> I hereby affirm that I am licensed under the provisions of Chapter 9(commencing with Section 7000) of <br /> Division 3 of the Business and Professions Code and my license is in full force and effect. <br /> License* -A1 C) A C_ Exp Date; "i- ' ) - <br /> Date:, Contractor:It `s �.� t t 31n �1_`t, 1aL�Q -riV <br /> Signature: A Title: <br /> Print Name:Z01"I ,(tS1{� `r 1 Y v s <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 /> 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.t ny� tl-i6 00lr*� 'y Volcy Number: <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 provisions of Section 3700 of the <br /> Labor Code, I shall forthwith comply with those provisions. <br /> Exp. Date: 1 - 1 ^ it7 Signature: t'Lm� <br /> PrintName: (1r)00.JLN F li,,:toofALowr A - <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 /> ATTORNEYS FEES.AND DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE" <br /> AUTHORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> I, ( ^k A (signature of C-57 licensed authorized representative), <br /> hereby authori a(print name) _. .-`�1Z Y1 it 2ri� O cn to <br /> sign this San Joaquin county Well Permit Application on my behalf. I understand this authorization is valid <br /> for one year and is limited to the work pian dated on the front page of this application. <br /> ar7awznlu <br /> 0102501 118x11 14WIt.Print I hf� <br />