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San Joaquin County Environmental Health Department Unit IV Well Permit <br />'IlicationrSupplement <br />JOB ADDRESS: //S3o a. 421, PERMIT SR#: <br />OS'/l 72- W <br />LICENSED 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 Business and Professions Code and my license is in full force and effect. <br />License #: '1 f 0 D-7 Expiration Date:- (97/3009 <br />Date: i o l3 00 7 Contractor, _ (il/DD,�wR�a !%>4 t:lJ AIA, t��yt�°rhr/Y� T-af/G <br />Signature: Itle: �t'-Sl-bcwr <br />Printed name:_ CcAg-- c, <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: NATE titNf7 Pollcy Number: 00 ZOZ38-- 2607 <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: 0 ZOOe Signature:Ua���m„ <br />Printed Name: CoNCINCr Cy, WVo pl,dA7" <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 />(signature ofC-67 licensed authorized representative), <br />hereby authorize (print name) Td D i) ffAC <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 />MM 29-02-001 <br />6/22/04 <br />