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San Joaquin County Environmental Health Department Unit IV Well Permit Application Supplemental <br /> JOB ADDRESS: rI�� �o S!, �� 1� �f�3��PERMIT SR# 0 2— <br /> LICENSED <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> 1 <br /> I hereby affirm that I am licensed under the provisions of Chapter 9 (commencing with Section 7000) of I <br /> Division 3 of the Business and Professions Code and my license is in full force and a ect. <br /> License#: Exp Date: l J� <br /> Date: Contractor: V V11PI <br /> 1 <br /> JJ <br /> Signature: Title: <br /> Print Name: <br /> 1 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 � � <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 /> Carrier: Policy Number: Ch1 <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 provisions. <br /> Exp. Date: D Signature: <br /> Print Name: l VIS 1�1� �I�✓�� <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 /> i ATTORNEY'S FEES,AND DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. <br /> FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> I, (signature of C-57 licensed authorized representative), <br /> hereby authorize(print name) M61-155'8 GT 2 kr11�;A./ ,to <br /> sign this San Joaquin county Well Permit Application on my behalf. I 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 /> 8129102JMI <br /> EHD29-011115107 WELL PERMIT APP <br /> I <br />