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�Mz • • <br /> San Joaquin Cour+• Environmental Health Department Unit IV Well Permit Application Supplemental <br /> JOB ADDRESS: O O o '',eedjAe Ptd Y PERMIT SR# 0�1 ` <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 <br /> /and Professions Code and my license is in full force and effect. <br /> License #: �da3<7"[ Exp Date: <br /> Date: Contractor: �,s� �'�' L•I n\ <br /> Signature: t� #ORKEFR;V' <br /> Title: � 401-cs�A � <br /> Print Name: <br /> 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 inssurannce-carrier and policy numbers are: <br /> Carrier: <�IGC/ L-6t�'�G' Policy Number: —1I 3155 3--I0t <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 forthwith comply with those provisions <br /> Exp. Date: Signature: <br /> Print Name: 1 <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 /> T R TIO FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> (signature of -57 licensed authorized representative), <br /> reby authorize (print n e) to <br /> sign this San Joaquin c unty Well Permit Application on my b half. 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 /> 8/29/02/MI <br /> WELL PERMIT APP <br /> EHD 29-01 11/5/07 <br />