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i ' PAGE 0'2/02 <br />,l0;'7� ✓� f <br />1N1 2094671118 AGE STOCKTON <br />YJ J9 �1b L L b: 41 2bJ4bd3433 FIFTH FLOOR PAGE 02 <br />San Joaquin Gnunty Environmental Haalth Departrnunt Unit IN well Pe►TnitApplication Supplement <br />'00 -JOB ADDRESS: 1111—Sowb� Cc.� � S��i�. PERMIT SR#: Q <br />D -- Q <br />LICENSED CONTRACTORS DECLARATION (LC17) <br />I hereby affirm that i am kensed under the provisions of Chapter 9 (commencing with Section 7000) of Dhrtslon <br />3 of the Business and Prcfesaions Cade and my license is In full force and effect <br />License #: �C�'Cs,�2 Expiration Gate. 1 2°Q - <br />Date_ <br />Signature: <br />Printed na <br />WORKERS' COMPENSATION DECLARATION <br />I herak)y affirm unditr penalty of perjury one of the following declarations: (CHECK ALL THAT APPLY) <br />I have and Will maintain a car-tificate of consent to self -insure for workers' compensation, as provided for by <br />Section 3700 of the Lebor Code, for the performence of the wont for which this permit is issuOd. <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 insurdnce <br />carrier and policy n4m'berss are: <br />Carrier: �1 C4-� AV� 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 ao as to become subject to the workers' compensation Jews of California, and agree that if 1 <br />should becorne subject to thf workers' compenwtlon provisions of Section 37Q0 of the Labor Code, I Shall <br />forthvAth comply with those provisions. <br />Date: 51gnature: <br />Printed Name: <br />WARNING: FAILURE TO SECURE WORKERS' COMPENSATION GOvERAGE IS UNLAWFUL. AND SHALL StJI9JEQ-r <br />AN VzMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br />($100.13M), IN ADDITION TO THE COST OF COMPEN5ATiON, INTER.i;ST, ATTORNEY'S PEES, AND DAMAGES AS <br />PROVIDCD FOR Ip ECTiO 06 OF THE OR COD <br />I, (signature Aft: -s7 Ilcarized authorized representative), <br />nerabv uthorlZefarintnamel <br />to sign this sen Joaquin County Well Parmft ApIIlicatlon on my behalf, I understand this authorizatlon Is valid for <br />one (1) year and is limited to the worse plait dated on tha front page of thin appil—tion, <br />1-25-021 AAI <br />