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LASERJET 3200 <br /> • P- 1 <br /> FBus!ness <br /> in County Environmental Health Department Unit IV Well permit Application Supplement <br /> SS: <br /> PERMIT SR#: <br /> LICENSED CONTRACTORS DECLARATION LCD <br /> hat I am licensed under the provisions of Chapter 9 (commenartg w th Section 7000)of Div cion <br /> s and Professions Code and my license is in full force and effect. <br /> Expiration Date: <br /> Contractor: <br /> Signature: <br /> Title: <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 /> by 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 required 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: P licy Number: <br /> I certify that in the performance of the work for which is permit is issued, I shall not employ any person in <br /> any manner so as to become subject to the workers' ompensation laws of California, and agree that if I <br /> should become subject to the workers'compensation rovisions of Section 3700 of the Labor Code, I shall <br /> forthwith comply with those provisions. <br /> Data: Signature: <br /> Printed Name: <br /> WARNING: FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CML FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> ($700,000.), IN ADDITION TO THE COST OF COMPENSATION,INTEREST,ATTORNEY'S FEES,AND DAMAGES AS <br /> PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. <br /> AUTHORIZATION FOR 077lER THAN C-57 SIGNING PERMIT APPLICATION . <br /> Ld f^A (signature ofC-57 0censed authorized representative), <br /> hereby authorize(print name) (! ( �1 0 (/�jr.� /(�� pZLAe,04�--X- 74-- <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 /> 8-29-021 MI <br />