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San Joaquin County Environmental Health Department Unit IV Well Permit Application SSupplegment I <br /> JOB ADDRESS: 1�;.ss`' JPERMIT SR#: <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> 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#: _ ( Expiration Date: <br /> Date: ' Contractor <br /> Signature: � Title: �r j1 <br /> r <br /> Printed name: 014 tr <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affir;n under penalty of perjury one of the following declarations: (CHECK ONE) <br /> have and will maintain a certificate of consent to self-insure for workers' compensation, as provided rcr <br /> b;1 Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. <br /> 1 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 issuea. Pity workers'compensation insurance <br /> carrier and poiicy numbers are: 1 C <br /> Carrier: + v�-t Fdtl 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 workers' compensation laws of California, and agree that if I <br /> should become subject to the workers'compensation provisions of Section 3700 of th,� L_bcr Code, I shaft <br /> forthwith comply with those provisions. <br /> Expiration Date: Signature: _ <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-57 SIGNING PERMIT APPLICATION <br /> I <br /> 1, `l�'+C(J/ 1 TK (signature ofC-57 licensed authorized representative), <br /> hereby authorize(print name) \ _�_ vi.1 �.-.,. «�•_ _._—_ <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/MI <br /> EliD 29-02-1101 <br /> 6/22/04 <br />