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San Joaquin County Environmental Health D artment Unit IV Well Permit Application Supplement <br />JOB ADDRESS: l� y PERMIT SR#: � 053 0r0 0 <br />L ENSED CONTRACTORS DECLARATION (LCD) <br />I hereby affirm that I am licensed under the provisions of Chapter 9 (commencing with Section 7000) of Division <br />3 of the BusinessandProfessions Code and my license is in full force and effect. / <br />License #: Ul I ��� Expiration Date: -tis 2-I U6 ✓ <br />Date: r 1 - 11 C ractor: GOC( <br />Signature:— Title: <br />Printed name: ! \C" Q 2Ck <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 />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: nhr5\,1 Policy Number: WC - 10 5 1 <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 thos4 provisions. <br />Expiration Date: � 7 Signature: <br />o Qo 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 />9C,4 LS_g ',h_ (signature ofC-57 licensed authorized representative), <br />hereby authorize (print name) <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 />EHD 29-02-001 <br />X22/04 <br />