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1 21-31 7 1995- .1 3 56PM FROM . <br />^ <br />rAa *4V 701 043U 1U 4 003 <br />San Jcurqui /IkonI Health =5, Unit IV Well Permit Application Supplement <br />JOB ADDRESS: tz-"--“T PERMIT SW: (96? P2-5 <br />LICENSED CONTRACTORS DECLARATION (LCD) <br />I horetry affirm that I am licensed under the provisions of Chapter 9 (commencing wtth Section 7000) of Division <br />3 of the Business and Prortessrons Code and my license is in full force and effect <br />License 0: (0 0 c'D 0 co Expiration Date: /-3/-oc( <br />Date: 47c; Contractor: rise...14 c;-() 4 6/7- <br /> <br />signature: <br />Printed name: vi (Y <br />WORKERS' COMPENSATION DECLARATION <br />I hereby affirm under penalty of perjury one of the following declarations: (CHECK ALL THAT APPLY) <br />_ I heVe 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 />_ j4' 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: ,5710 "A9 4X)(1.0 Policy Number: <br />I certify that in the performance of the work for which this permit is issued, I shall not employ any pereon in <br />arty rnanrrer so as to become subject to the workers' compensation laws of California, and agree that ill <br />should become subject to the workiars' compensation provisions of Section 3700 of the Labor Code, I shall <br />forthwith comply with those orovisione. <br /> si 9nature:'- <br />Printed Name: —Davi sOl <br />WARt+IING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAOE IS UNLAWFUL, AND SHALL SUBJECT <br />AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOU.ARS <br />($100,000.), 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 />(signature otC-57 licensed authorized representative), <br />hereby authorize (print name) PA17,04,—t.ç ç ArceeLv • <br />to sign this San Joaquin County Well Permit Application on My behalf. I understand thls authorization la valid tor <br />one (1) year and la limited to the work plan dated oil the front page of this application. <br />5-17-2000 Ml <br />/58(0 QCS- 6/ <br />Date: