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Y t <br /> San Joaquin County Environmental health Department Unit I Well Permit Application Supplement <br /> JOB ADDRESS: a333 S, Ni4m± Wc, PERMIT SR#; <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#:�Y'S (d 0 U1 Expiration Date: <br /> Date: 10 _�u n e_ QW 3 Contractor: e n V i ro;?c aloe. <br /> Signature: — Title:, <br /> Printed name: fSOB� <br /> WORKERS' 11: MPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the following declarations: (CHECK ONE) <br /> 1 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 nurmber{s� are: <br /> Carrier: Policy Number: <br /> 1 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 Califomia, and agree that if 1 <br /> should become subject to the workers'compensation proviss tion 3700 of the Labor Code, I shall <br /> forthwith comply with those provisions'. <br /> Date, ie -5 Signature: I 7_ <br /> Printed Name' A�" U <br /> WARNING: FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UJAWFUL,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 /> AUTHORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> (signature ofC-57 licensed authorized representative), <br /> hereby authorize(print name) <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 /> 8-29-021 MI <br />