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i <br /> San Joaquin County Environmental! Health Department Unit IV Well Permit Application Supplement <br /> JOB ADDRESS: �dV_/VY 51VI- PERMIT 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 Division <br /> 3 of the Business and Professions Code and my license is in full force and effect. i <br /> License#: &60 ZZ Expiration Date: <br /> Date: MelContractor: <br /> Signature: Title:V. <br /> �� <br /> Printed name: <br /> WORKERS' COMPENSATION DECLARATION <br /> thereby affirm under penalty of perjury one of the following declarations: (CHECK ONE) . i <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 Cade, for the performance of the work for which this permit is issued. r <br /> 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: Y <br /> Carrier: Policy Number: J .I 7.J 1 <br /> r <br /> I <br /> I certify that in the performance of the work for which this permit is issued, I shall not employ any person in <br /> any manner so as to become subject to the workers'compensation laws of California, and agree that if) <br /> should become subject to the workers'compensation provisions of Section 3700 of the Labor Code, I shall q <br /> forthwith comply with those provisions_ <br /> f <br /> Expiration Date: �� 0� Signature: <br /> s <br /> Printed Name: <br /> WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> ($100,000.), 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 OTHER THAN C-STSIGNING PERMIT APPLICATION <br /> i <br /> b (signature ofC-67 licensed authorized representative), <br /> hereby authorize(print name) <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 /> 8-29-02 1 MI <br /> i <br /> E]D 29-02-001 <br /> 6/27/04 <br />