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San Joaquin County Environmental Health Sorvicas. Unit IV Well Permit Application Supplement <br />JOB ADDRESS: PERMIT SR#: <br />LICENSED CONTRACTORS DECLARATION (LCD) <br />I hereby affirm that I am licensed under the proviatons of Chapter 9 (cOMmencing with Section 7000) of Division <br />3 of the 3usiness and Professions Coda and my license is in full force and effect. <br />License 4: ( 0 , Y.- -zai 7— .xpiration Date: CQ —3 0 — 03 ..... <br />Date: 0 — ? Contractor: i . i I <br />Signature: JIM, Irf ''' /1 e 41_1(-- Title: <br />Printed name; a..1 / .7TX <br />WORKERS' COMPENSATION DECLARATION <br />I hereby affirm under penalty of perjury one of the following declarations: (CHECK ALL THAT APPLY) <br />have end will maintain a pertifioato of consent to self-insure for workers compensation, as provided for by <br />Section 3700 of he Labor Code, for the performance of tha work fOr which this permit is issued. <br />Nr, I have end will maintain worker3' compensation insurance, as required by ei...lion 3700 of the Labor Code, <br />for the performance of the work for which this permit is issued. My workers' compensation insurance <br />oerrier end policy numbers are: <br />-fil- i; Aid <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 mariner so as to become subject to the workefs' compensation laws Of California. and agree that If I <br />should become subject to the workers' compensation provisions of Section 3700 of the Lubor Code, I Mall <br />forthwith comply with those provi5ton5. <br />Date: Signature; <br /> <br />or. <br /> <br />Printed Name; <br /> <br />WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUEJECT <br />AN EMPLOYER TO CRIMINAL PENAL71ES AND CIVIL rIfstES UP TO ONE HUNDRED THOUSAND DOLLARS <br />$ 1 0 0 0 0. ) , IN ADDMON TO THE COST OF COMPENSATION, INTEREST, ATTORNEY'S FEES, AND DAMAGES AS <br />PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE <br />frj 4 <br />I, JAW) e (C-57 lIcensed atithorqed repriKentatiVt), herictry <br />authorize PA- 0-1 qLLA rIic J <br />to sign this San Joaquin County Well Permit AapilcatIon on my behalf. ( understand this authorization is vatid fat <br />one (I) year and Is limited to the work plan dated on the front page of this app4catIon, <br />5-17-2000 / MI <br /> <br />Carrier.- Policy Number: 1 S-8 (1 Cc <br />5pt9 7 `I' I/