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�r F -I. TH FLOOR <br />1E_�:''23r'' 7Ei1 13:1' 20946334._ <br />San Joaquin County Environmental Health Services, Unit IV Well Permit Application Supplement <br />��L �D✓a.�-c� PERMIT �SR#: Q� <br />JOB ADDRESS: 6 o ?�24(I <br />LICENSED CONTRACTORS DECLARATION CLCD) <br />I hereby affirm that I am licensed under the provisions Chapter ull force and n#g. with Section 7000) of Division <br />` 3 of the Business and professions Code and my licenseis <br />License #: <br />Expiration Date: LA 1;Q <br />r ail? 1���M i <br />Date: n ractor :I <br />Signature' _ _ t Title: <br />n <br />Printed name: s 1A,2 r <br />WORKERS' COMP EN SATION'DECLARAT"IUN <br />I hereby affirm under penalty of perjury one of the following declarations: (bHECK ALL THAT APPLY) <br />I have and will maintain a certificate of consent to selfof the work forfor kwhichjthip permit s issued.provided for by <br />Section 3700 of the Labor Code, for the performance <br />V/ I have and will maintain workers' compensation insurance, as required by lection 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: 1� ri Policy Number: <br />I <br />_ I certify that in the performance of the work for which this permit is issued, <br />any manner so as to become subject to the workers' compensation laws ( <br />should become subject to the workers' compensation provisions of Se/ io <br />forthwith comply with those provisions. /1 <br />Date: �' ii <br />shall not employ any person in <br />California, and agree that if 1 <br />3700 of the Labor Code, I shall <br />Printed Name: - <br />WARNING: FAILURE T8 bEEURE W61"p49' OOMpr_NOATIGH 0oUCnAQC 10 UNLAuumt-, A11D CWAI I R1I2.IGCT <br />AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br />(S1oo,000.), IN ADDITION TO THE COST OF COMPENSATION, INTEREST, ATTOR�EY'S FEES, AND DAMAGES AS <br />PROVIDED. FOR IN SECTION 3706 OF THE LABOR CODE. <br />(signature ofC-57 R nsed authorized representative), <br />.� - 0 <br />hereby authorize (print name) � �� � 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 applic <br />5-17-YUuu r ivu <br />