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I <br /> kL;,eel ed Far:: H124J09 03:19PeFax Station: All Vee 1 kbandon ant `"� p,04 <br /> Sen Joaquin County Environmental Health Department l nit IV Well Permtf Application supplanientiil <br /> JOB ADDRESS: i ; wiloPI: Mr SR# <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> If—I I w...IkK.,,MV41 v.n,l. qgf t's-10IV,'a Vr 01,.,Nl� t4ul„ „Di,y �•r111,oauirU„TOdO)VI <br /> Division 3 of the Business and Professions Code and my lic:nse is in full force and effect. <br /> License#: Q/1 � w__ E -(p Date:,1(A g?„a <br /> Date: r 2:5 109 Co i1ractOLIJ - <br /> Signator Title. • <br /> Print Name• axt\ z, ta[i .g <br /> WORKER'S COMPENSATI011 DECLARATION <br /> 1 hereby affirm under penalty of perjury one of the Following fecfarations:(chock one) <br /> I have and will maintain a certificate of consent to s(tf-insure for workers'compensation,as <br /> provided for by section 3700 of the labor Cade,for t 1e pedurmame of the work for whim this <br /> Permit is issued. <br /> 1 hAVP,and wflLMaJj1tAln wnrkprn'rnrmmnsaWn instrance, ac squired by Section 3700 of tho <br /> Labor Code, for the performance of the work for whl:h this permit is issued. My workers' <br /> compenswion Insurance carrier and policy numbers are: <br /> Carrier:%= fino Policy Numb rr: 0.1--100 0— 06 <br /> I certify tNat in the performance of the work forwhicll this permit is issued, I shall not employ any <br /> person In tiny manner so as to become subject to th?workers'compensation law of Califo mia, and <br /> agree that if I should become subject to workers'co npensation provisions of Section 3700 of the <br /> Labor Code, I shall <br /> {forttrMth comply with those Prov skins. <br /> Fxp,natA: l���- Slgnattu <br /> Print Na <br /> WARNW:fAILURI TO SECLWE WOMRW COMPENSATION COVERAGE E5 UNLAWFUL,AND SHALL SUBJECT AN EMP40YER TO <br /> CRANNAL PENALTIES AND CML FINES UP ToS100,0 0,IN Apr ITION To THE COST OF COMPENSATION,INTEREST, <br /> ATTORNE"FEES,AND DAMAGES AS PROVIDED FOR IN 8EC'M 1706 of THE IJUSOR CODE. <br /> i, AV]HORI�ATI N FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> (1 (signature:of C.57 licensed authorized representattva), <br /> hereby Authorize(prin arise) to <br /> sign this San Joaquin y Wrtl Permit Applica o o s� <br /> ; aif. t undoretand thlc auttsoricution to valid <br /> for one year and Is limited to the wort[plan dated on the from page of thts application. <br /> anflmznw <br /> CMDMOI s+W <br /> fit:PERU rAPP <br />