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'WORKERS' COMPENSATION OECLARATION <br />I hereby affinn Linder penalty of perjury one of the following decJaraticas: (CHECK ONE) <br />I here and will maintain a certificate of consent to self-Insure for workers' c.ompennation, as provided for <br />by Section 3700 of the Labor Code, for the performance of the work for which this permit is Issued, <br />,>‘z_ I have end 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 ere: <br />Carrier: Policy Number, <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 lows 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 oomply with those provisions. <br />Expiration Date:5„a,z, Signature: <br />Printed Name: __Le_e_Ok5z, <br />WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT <br />AN ENIPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRSD THOUSANI:3 DOLLARS <br />($100,000.), IN ADDITION TO THE COST OF COMPENSATION, INTEREST, ATTORNEY'S FEES, AND DAMAOES AS <br />PROVIDED FOR IN SECTION 3705 OF THE LABOR CODE. <br />AUTHOR! TION FO/ OTHER THAN C.57 SIGNING PERMIT APPLICATION <br /> (signature ofC-S7 licensed authorized representative), <br />to sign this San Joaquin COunty Well Permit Application on my behalf. luridereand this authorization It valid for <br />one (1) year And is limited to the Work plan dated an the front page of this application. <br />8-29.02I MI <br />hereby authorize (print name) <br />J 1111111 1111V1,11ULU UUVLIIV I 11)1111117.11L01 IV.. LLI•f0 1. z <br />6W- I <br />San Joaquin County Environmental Health Department Unit IV Well Permit Application Supplement <br />JOB ADDRESS: LIY05 AL;FA, /Leto PERMIT $R#: 00 VV.5-9 <br />(r741t," <br />LICENSED CONTRACTORS DECLARATION (LCD) <br />I hereby affirm that I am licensed under the provisions of Chapter 9 (commencing with Section 7000) of Dhision <br />3 of the Business arid Professions Code and my license is in full force arid affect, <br />License I: 'S( ty- Expiration Da t 0 <br />Date: (5=5. . Con otor: <br />Signature: Cr—z,,e-1 Title: <br />Printed name: <br />MD 29-02-001 <br />6=04