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t209J772-3571 p . 2 Chris Fisch Dec 14 00 08:22a <br />Dsc.13, 200) 11:0941 CONCOR EARTH TECHUDGIES 0.1126 P <br />, <br />I San Joaquin County Environmental Health Services, Unit IV Well Permit Application Supplement <br />JOB ADDRESS: ic;(52tfL-3710/9i,A-/-1:i 0.6 PERMIT SR#: <br />LICENSED CONTRACTORS DECLARATION (LCD) <br />hereby affirm that I am licensed under the provisions of Chapter 9 commencing with Section 7000) of nivision <br />3 of the Business and Professions Code and my license is in full force and effect, <br />License #: ;?((/ Expiration Date: / -3/-0 ;2--- <br />Date: /cV -()() Contr. ctor. JETne.1-1 AT/7 V i (illti21 ZA__72 z-7 <br />Signature: • 017. Title: <br />Printed name: --1)0 /ITS (7,4 <br />WORKERS' COMPENSATION DECLARATION <br />t hereby affirm under penalty of perjury one of the following declarations (CHECK ALL THAT APPLY) <br />A '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 Coce, <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: \,.." (2(.22/ Policy Number: I 5. j3(21 9O 5 -- 00 <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 <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: A() d Signature: Z.77 <br />Printed Name: <br />WARNING; FAILURE TO srcuRe WORKERS' COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT <br />AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br />0100,0004, IN ADDITION TO THe COST OF COMPENSATION, INTEREST, ATTORNEY'S FEES, AND DAMAGES AS <br />PROVIDED FOR IN SIC HON J706 OF THE LABOR CODE. <br />(C -57 licensed authorized representative), hereby <br />authorize <br /> <br />to sign this San Joaquin County Well Permit Application on my behalf. I understand this authorization is valid for <br />Lpne (1) year and is limited to the work plan dated on the front page of this application.