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� rvnm iivv une�u e L a L u v i i o q ry r.n L a 1 IY V. /-4'10 r. L <br /> San Joaquin County Environmental Health nnDopartment Unit IV Well Permit Application supplement <br /> JOB ADDRESS: ill PALIFL r veAV e_ PERMIT SR*: D sl <br /> S-To r-r-m q LA <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. <br /> License if: 7 J�C Expiration Da I — I "O <br /> Date: I D —I t— 6`; Con <br /> Signature: Title: <br /> Printed name: ar, r qe Qjuk- <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'compannatien, as provided for <br /> by Section 3700 of the Labor Code,for the performance of the work for which this permit is Issued, <br /> have and will maintain workers'compensation insurance, as required by Sectlen 3700 of the Labor Code, <br /> for the performance of the work for which this permit Is issued. My workers'compensatlon Insurance <br /> carrier and policy numbers arr�e::�r�`►� <br /> Carrier- 't'" QIA� I V l7LA ' 1n0J Policy Number, <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 workars'compensation laws of Califomle,and 2gree that if I <br /> should become subject to the workers'campensatien provisions of Section 3700 of the Labor Code, I shall <br /> forthwith comply with those provisions. <br /> Expiration Dater '( ^(S(p Signature: ( –! <br /> Printed Name:_ ('Ill�� "f l 1 . 1 Q f iry.- ,- <br /> WARNINi3_FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL.,AND SHALL SUBJECT <br /> AN EMPLOYFR TO CRIMINAL PENALTIES A140 CNIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> ($100,006.),IN AODITION TO THE COST OF COMPENSATION,INTEREST,ATTORNEY'S FEES,AND DAMAGES AS <br /> PROVIDED FOR IN SECTION 3700 OF THE LABOR CODE. <br /> AUTHORI�-TION FOr, THAN C-57 SIGNING PERMIT APPLICATION <br /> (signature ofC•57(Icensed authorized representative), <br /> herebyauthorizo(printname) <br /> to sign this San Joaquin county Well PermitApplieatinn on my behalf. I understand this authorization It valid for <br /> one(1)year and Is I:mited to the work plan dated an the front page of this appilaaflon. <br /> 8-29.42 f MI <br /> PFItt 29-02.001 <br /> br�roa <br />