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buy, C 7 V <br /> .1 U 0 11 -t I d rl 1 i,1 L I i I 1 1 r, 707— -9045 <br /> PIC <br /> San Joaquin County EnAronmental Health Department Unit IV Well Pafmt Applcatlon Supplem <br /> f <br /> 1 JOB ADDRESS: ?L7_ CA PERMIT SR#: f <br /> UCENSEID CONTRACTORS DECLARATION (LCD) <br /> I hemby affirm That I am licensed under V-&-proovanz of Cti*er 9(nornmeming vai Seciion-ruua)of Division <br /> 3 of the ausfne.cz and Pfofn!miarts cocie and my iscenze is in full force and enW, <br /> iO <br /> E*raWn D aw-, <br /> Date. GrontrectDr. <br /> 7 <br /> Pliked name; <br /> WORKERS'COMPENSATION DECLARATION <br /> I here-tv affirm linder penalty of pejury ore of Oe idiumng deQLvarims- (CHECK ONE) <br /> I hsve,anis%mA maintain a 666ficWe ct=*ont to Self-insure liar workers'compeneaDon, as providad fof <br /> by Section 3700 of the i z;bou rude,for the perfonnance of the work for which this puana is W'uuec. <br /> Ill;iv.and will ffrarntai',Womer's,c01Wcn6d5uFi Insufance'•as zvquimd by Section 3700 of the Labor Code. <br /> tir:he performance of Ow work for which this parmil.is 4saued. My%wrlkens'compeneeiari insunaoGe <br /> i <br /> Carrier and PqNcy nLMftrS am, <br /> Potit;Y Number; <br /> Carrier. TV <br /> certify that in the performance&j tha vtork'bf Wfuch this penTiA i5 issued,I sbajl not employ any person In <br /> any manner so as to tauoma subjeo to the woj-kCM'wMP6n8adon 4ows of CaWornla,and agree tht.1 if I <br /> shoUd be-corno wbject to 0*woskem'(=ipensafior provisions of Z-fion 3700 of the Labor Code, I'%n'arl <br /> fOFtMth comply Oth ftse 9fQVj5jUn,%. <br /> Expiraliun Signature= <br /> Printed Name: <br /> WAARING;FAILUR5 TO SECURE WQRK&R5'COMPEt4W,1ON ijovERAGE 1$UmLJkWr-ui_,AP40 SHALL SUWEG <br /> AN EMPLOYER TO CRIMINAL PENALI?Es sN%D CIVIL-FINES UP To oiyL HUNDRED THOUSAND DOLLARS <br /> IN ADDITION TO n4L 00$Y OV COMPEwATto4. .tNTelzEsT.ATTORNVy-5 FEES,AND IJAMOLQE5 A5 <br /> PRCMDED FOR IN SECTION 37C6 OF THF LAF30R CODE. <br /> AUTHORiZATION FOR OTHER THAN C-57 SIGNING PERW r, APPLICATION <br /> J, <br /> I_ wignatum nEC-67 firefmed atuthortzvd rvprvr'onta16vvj, <br /> Newby atdbg rize(print nanw)_jr- <br /> to-.1go this$A"Joaquin County well Pe rfflk"Pitt-Abon an my behalf. I uoderrstand this autheTlizatkin is valid fpr <br /> orm(1)yont,ind is Ilwated to the work plan daloo on the front puge tat"this <br /> Lia-W_1M I_ <br />