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AUT •po - IZ • TION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION • <br />(signature ofC-57 licensed authorized representative), <br />r <br />I. <br />San Joa. <br />r"- <br />County Environmental He h Department Unit IV Well Permit Application Supplement <br />Ittl) <br />JOB ADDRESS: "rb,w PERMIT SR#: 3"t•S'.1 Y-- <br />LICENSED CONTRACTORS DECLARATION (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 />License #: -7 "7 S ' <br />Date: 1— <br /> <br />Expiration Date: IS )) <br /> <br />Ce tractor: CA--A-c LL,'-' <br /> <br />Signature: Title: Opera 717 0 /75 ay e //- <br />Printed name: Ve rcu. 4 c p rb'? c cm <br />WORKERS' COMPENSATION DECLARATION <br />I hereby affirm under penalty of perjury one of the following declarations: (CHECK ONE) <br />I have and will maintain a certificate of consent to self-insure for workers' compensation, as provided for <br />by 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 />Carrier: illOSACk_ jt/t pOvia I Policy Number: O3 3 ( <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 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: 7- - c2--/ —o 3 Signature: <br />Printed Name: -1,1 a <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 />($100,000.), 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 />hereby authorize rint name) --C\rt e U-' (-- <br />to sign this San Joaquin County Well Permit Application on my behalf. I understand this authorization is valid for <br />one (1) year and is limited to the work plan dated on the front page of this application. <br />8-29-02 / MI