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Faffirm <br /> unty Environmental Health Department Unit IV Well Permit Application Supplement <br /> S9 J'O r<c,. wJoVl p r, (�cL PERMIT SR#: <br /> CENSED CONTRACTORS DECLARATION (LCD) <br /> 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#: 40 / Expiration Date:_ OJ"l� <br /> Date: Contractor, �+'-PCIQ <br /> Signature: <br /> Title: <br /> Printed name: M a <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' compensation, as provided for <br /> by Section 3700 of the Labor Code, for the performance of the work for which this permit is Issued. <br /> A, I 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 issued. My workers'compensation insurance <br /> carrier and policy numbers are: <br /> Carrier: k� tL V" S h Policy Number: 5 e� j o`T oz-(-p ) <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 the Labor Code, I shall <br /> forthwith comply with those provisions. <br /> Expiration Date:_?LL_-QLisignature: <br /> Printed Name: �_ _ dA— <br /> WARNING: FAILURE TO SECURE WORKERS'COMPENSATION ERAGE 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 /> Lhereb <br /> L� r�' �I-�<(/ / (signature ofC-57 licensed authorized representative), <br /> authorize(print name) +"L k4 . /� <br /> this San Joaquin County Well Permit Application on my behalf. I un erstand this authorization is valid foryear and is limited to the work plan dated on the front page of this application. <br /> 1 MI <br /> EI I D 29-02-0U I <br /> G22iO4 <br /> z - d 9IL9E1E926 uaplen R.2ell e6T : TT SO ST 9aj <br />