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04; 008/2al.2 MON, 14;; 06 FAX <br />P <br />9wJl <br />e 1001 <br />San ,loaqutn County 6nvironmontal Hsalth Services, Unit.,IV Well Permit ApplicationSupplement <br />JOB ADDRESS: 6" 0 AJ • PERMIT Sly#: I / J `- / <br />LICENSED CONTRACTORS DECLARATION! (LCD) <br />I hereby affirm that I am licensed under the provisions or Chapter) (commencing with Section 7000) of Division <br />3 of the Business and Professions Cade and my license is in full force and effect. <br />License : �Cp 0�1 <br />Date: L' 0 c� <br />Signature: <br />Printed name•doe <br />Expiration Date: <br />clot: 1%A 1,L� Drr llin7� -� C _ <br />WORKERS' COMPENSATION DECLARATION <br />I hereby affirm under penalty of per)ury one of the following declarations: (CHECK ALL THAT APPLY) <br />I have and will maintain a certificate of consent to self -insure for workers' compensation, as provided for by <br />.� 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: C a t t11� t Policy Number: <br />`^ # cerWy 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 sub)ect to the workers' compensation laws of California, and agree that if) <br />should become subject to the workers' compensation provisions of S%tion 3700 of the Labor Code. t shall <br />foTthwlth corr ply with those provisions. ^ J'' 1 <br />Date: Signature: l <br />Printed Name: I(�C:l� <br />WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE 13 UNLAWFUL, AND SHALL SU9JECT <br />AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br />(S100,000.), IN ADDITION TO THE CAST OF COMPENSATION, INTEREST, ATTORNEY'S FEES, AND DAMAGES As <br />PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. <br />7 <br />! ,r' (C-57 licensed a fiorizedpresentativoj, heretry <br />r <br />authorize�--�—�— <br />to sign Phis Sart Joaquin County Well PennitApplicat on 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 />