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San Joaquin County Environmental Health <br /> �Department unit tv Walt Permit Appgiiotion supplemental <br /> JOB ADDRESS: �0%�e/NZ `!'+ 4 'en`PERMIT Sit# <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> 1 hereby affirm that I am licensed under the provisions of Chapter S (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#: �1 l t� '1 ExpDate: -1-3N - t <br /> Date: k,12— Contractor: <br /> Signature: Title: an I'd kold <br /> Print Name: r ��i*.._L X:2tit , i <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 polo�licy numbers are: <br /> Carrierila}jfy�;jtyLL"00 rt,� rahcy Number: a['t- (�`i<S_l__ <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 t 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; 1t3_1 - kb Signature; <br /> Print Name: t1�,5 IatiG�Cu' t + <br /> WARNING: FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT AN EMPLOYER TO <br /> CRIMINAL PENALTIES AND CIVIL FINES UP TO$104,000,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 /> AUTHORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> At ln,a (signa`ture of C-57 licensed authorized repfescntative), <br /> hereby authori a(print name) hof Jc to <br /> sign this San Joaquin county Well Permit Application on my behalf. I understand this authoraation is valid <br /> for one year and is limited to the work plan dated on the front page of this application. <br /> Yda ,RM.t.Wx <br /> rYgl24q` tyytl' <br />