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San Joaquin County Enviro sntal Health Department Unit IV Well r mit Application Supplemental <br /> ,I�� S`Tncl,rc'l �" <br /> JOBADDRESS: 2-500 /VNy!tD(-ltr,- PERMIT SR# Sol -I�`r <br /> IS ICc<T10A5' an epkATy r,9h1-afwGr <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#: Exp Date: <br /> Date: 410- 20 )O Contractor: <br /> Signature !S Title: Old e <br /> Print Name: �DA/td <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: `' 1 <br /> Carrier344Chm t Policy Number: O 10 brtS— Oq <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 pr visions. <br /> Exp. Date: �- I ' 2010 Signature: /S <br /> Print Name: 1`71 r� c5 <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 /> AUTPgRIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> 1, 2 (signature of C-57 licensed authorized representative), <br /> hereby authorize (print name) 1. )I N6 k� a-� 1�0�2 j 0.'��-Yt+ =ec h ,to <br /> sign this San Joaquin county Well Permit Application on my behalf. 1 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 /> 8129l02IMI <br /> EHD 29-01 11907 WELL PERMIT AT <br />