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JA!11@1q0 <br />San Joaquin County Environmental Health Servicus, Unitt W Well Permit ApPllcatlon SlipP19M ant <br />J48 ADDRESS::3�"/� _ f�PERMIT SR#: <br />LICENSED CONTRACTORS DECLARATION (LCD) <br />I hereby affirm that) am licensed under two provisions of Chspter 9 (cammenctng with Section 7000) of .Division <br />3 of the Business and Professions Coda and my Ilcense is in full forca and effect. <br />LiC-8nae 4: LQ I Z / Expiration Date: La '-� () — 0.3 <br />Gat©: <br />5lgnature: <br />Printed name: <br />WORKERS' COMPENSATION DECLAR.AMM <br />I hereby afri". under penalty of perjury one of the following d"larations: (CHECK ALL THAT APPLY) <br />_ I have Gnd will maintain a ceiVicats of consent io self -insure for workers' aompeinsaWn, as pwovldod for by <br />Section 3700 of no Labor Coda, for !be perfannance of tha work for which this permit is Issued. <br />I nave and will maintain workers' compensation insurance, as required by Seclion 3700 of the Labor Code, <br />f far the performancs of the worts for which this permit is issued. My warkars' compansa!Jon insurance <br />carrier and polis 1 numbena are: <br />CC +r L <br />CarrierPolity Number. <br />I cartify that in the performance or the worts for wtric."t this permit is issued, I shall not employ any parson in <br />ony manner so as to become sutjest to the workers' Compensation laws of California, and agree that if I <br />shouid become subject to die workafs' compensation provisions of Section 3700 of the Labor Code, I shall <br />forthwith comply with thoGa provisions. <br />Date: Signature: <br />Printed Name. <br />WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAQE 19 UNLAWFUL, AND $HALL SU6JVCT <br />AN EMPLOYER TO CRWINAL PENALTIES AND CNtL FINES UP TO ONE HUNDRED THQUSAND DOLLARS <br />;1D0,000.), IN ADDITION TO THE COST OF COMPENSATION, INTEREST, ATTORNEY'S FETES, AND DAMAGES AS <br />PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. <br />(C-57 Ilcansed sulhorl2ed reprt4entatiye), herkt<y <br />authorize 1 J 0 5 J� s� Y� ��Lt-_-F <br />to atgn this San Joaquin County Well PermltAlwicstion on my behalf. I undorstautd this authariratlen is watld far <br />one 41) year and Is limited to tttework arum dated on tho front page of this apptication, <br />5-17-20001 MI <br />