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:p� d, <br />'�(a d % <br />N , UW/ 8 z l <br />'an Joaquin County lELLnvironmental Health Department Unit IV Well Permit Application Supplement <br />JOB ADDRESS: 34i() 5 -A. -if 1 �- PERMIT SR#:li5 3 <br />LICENSED CONTRACTORS DECLARATION (LCD) <br />I hereby affirm that I am licensed under the provisions of Chapter 9 (commencing with Section 7000) of ivision <br />3 of the Business and ss de d my license is in full force and effect. 0(0 <br />License #: C57 Expiration Date: t <br />Date: 10- G ` a <br />Signature: <br />Printed name: <br />t4 t <br />Title: <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: I l " Policy Number:n SE(� <br />certify that in the performance of the work for which this permit is issued, I shall not employ any persun 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 />Date: / d -- Signature: M <br />Printed Name:G�&I!AC?7 <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 R OTHER THAN C-57 SIGNING PERMIT APPLICATION <br />1. (signature ofC-57 licensed authorized representative), <br />hereby authorize (print name)__LJ 1'Yl <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 />