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'' 7 .•r a..,,� <br />�4 k 17(f 7 48a n Jones 5-9451 P• 2 <br />r� <br />6,4�17r <br />San Joaquin Coun Environmental H Ith Services, Unit IV Well Permit Applicationv�sp��5 Supplement <br />/06.!,' !'o ezaa L 1 <br />JOB ADDRESS: tgo9 PERMIT SR# G J <br />• LICENSED CONTE ACTORS b.EC�'ARATIO'NN (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 />II p Expiration Date: <br />License, + <br />Date: 4- t Z--0 Contractor: RsuA En') - <br />Q <br />Signature: Title - <br />Printed <br />Printed name: �� S <br />WORKERS' COMPENSATION DECLARATION <br />I hereby affirm under penalty of perjury one of the following declarations (CHECK ALL THAT APPLY) <br />_ I have and wiil 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 />Policy Number: J <> ea 0 /C v 5-( <br />A. <br />Carrier: <br />_ I certify that in the performance of the work for which this permit is issued, 4 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 />Date: q- I a -O\ Signature: <br />Printed Name:�1r� <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 />($100,009.), 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 />• r <br />authorize <br />to sign this San Joaquin County Well Permit Application on my behalf. I understand this authorisation is valid for <br />one (1) year and is limited to the work plan dated on the front page of this application - <br />5 -1 7-20UU <br />pplication. <br />5-17-2000 I M1 <br />ccncoancn7 / L' :10 TCIC17 /7T /bq <br />