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San Joaquin County Environmental Health Department Unit IV Well Permit Application Supplemental <br />Rrejty1A I ' 1-1 <br />LICENSED CONTRACTORS DECLARATION (LCD) <br />I hereby affirm that I am licensed under the provisions of Chapter 9 (commencing with Section 7000) of <br />Division 3 of the Business and Professions Code and my license is in full force and effect. <br />License #: 1 - C-, -1 E xp Date: JL) ZU09 <br />Date: 9A N r G _ Contractor: _ j llflnC�rl '(��r1UI�T11111�I'l�t � 1 11( _ <br />Signature: Title: \'i (i 1�► P, llF' i'1+ <br />Print Name: R& <br />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 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: <br />�tct+� C'Dr�1�f�srxrion <br />Carrier: InStirpoc e Fund Policy Number: `3 / 4 '- -_200-1 <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 shill forthwith comply with those provisio <br />Exp. Date:_.,,.,.. / _ Signature: <br />Print Name:t''�C'wi L . Mrar <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 />ATTORNEY'S FEES, AND DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. <br />AUTHORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br />(signature of C-57 licensed authorized representative), <br />hereby authorize (print name) <br />, 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 />8/29/02/MI <br />EHD 2MI 11/5/07 WELL PERMIT APP <br />