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San J In ounty Environmental Health Department Unit IV Well Permit Application Supplemental <br /> � <br /> JOB ADDRES& ��6 LV AJ` PERMIT SR y# S S[l Jup3 <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> I hereby affirm that I am licensed under the provisions of Chapter 9 (commencing with Section 7000)of <br /> Division 3 of the Business and Professions Code and my license is in full force and effect. <br /> License#: 1 7 80 -1 Exp Date: �aI 1 3-D`j)[C)Date:pe//i/ g O Contractor: Ue-6-r l4-ear+ -On R(' <br /> ✓)Q <br /> Signature: dU4-/` W Ly� Title: <br /> Print Name: ISP� <br /> WORKER'S 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 <br /> provided for by section 3700 of the labor Code, for the performance of the work for which this <br /> permit is issued. <br /> I have and will maintain workers' compensation insurance, as required by Section 3700 of the <br /> Labor Code, for the performance of the work for which this permit is issued. My workers' <br /> compensation insurance carrierandpolicy numbers are: <br /> Carrier: t � d Policy Number: i 3 - V(P .-).7_O ) <br /> I certify that in the performance of the work for which this permit is issued, I shall not employ any <br /> person in any manner so as to become subject to the workers' compensation law of California, and <br /> agree that if I should become subject to workers' compensation provisions of Section 3700 of the <br /> Labor Code, I shall fo h`witth comply with those provisions. <br /> Exp. Date: 1/J) I l�Q �° Signature: <br /> �� WUVL <br /> Print Name: <br /> WARNING: FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT AN EMPLOYER TO <br /> CRIMINAL PENALTIES AND CIVIL FINES UP TO$100,000,IN ADDITION TO THE COST OF COMPENSATION,INTEREST, <br /> ATTORNEY'S FEES,AND DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. <br /> ALITHOUI KK TION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> I, �Grrl ww I,T-(�!— (signature of C-67 licensed authorized representative), <br /> hereby authorize (print name) R-D 6Et� 14% F-); '� , to <br /> sign this San Joaquin county Well Permit Application on my behalf. I understand this authorization is valid <br /> for one year and is limited to the work plan dated on the front page of this application. <br /> S/29/02/MI <br /> EH0 29-01 11/5/07 WELL PERMIT APP <br />