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08/04/2005 THU i5:26 FAX • <br /> /� • J UU: <br /> L2!26�3Nt7F; 170:;9 5iE•r;t,ala l_L�/ .R"fIR - <br /> f 1/a 3 tJ. /651wl /;;/i U, /85�gd z9 5 <br /> Sir.Ja7q!Iin�rnmty F_nvironmental Health Department Unit IV Well Permit Appltcaliu Sull A men( <br /> JQ8 ADDRESS__`-15 ) -'' - PERMIT SR#:� 33 �- <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 <br /> sand <br /> PrProfessions Code and my license is in full force and NI-QnDqte; <br /> tj <br /> License O J � 1 fi E�xpQi' '�1lX <br /> Date, _Contra tor: �1�� <br /> Signature; hh i �_TTtte; <br /> Printed name: �— <br /> WORKEt2S' COMPENSATI DECLARATION <br /> I hereby affirm under penalty of perjury one of tho following declarations: (CHECK ONE) <br /> I have and will maintain a certificate of wnaent to self-insula for workers'compensation,as piovlded for <br /> by Section 3700 of the Labor Code, for the perfoonancr of the work for which this porrilit is issued. <br /> I have and will maintain Workers'compensation insurance, as required by Seation 3700 of the Labor Cotle, <br /> for the performance of the work for which this permit is issued. My workers'compensation insurnnce <br /> carrier anTpolicy numb . are: <br /> Carrier. ��a ,, C' Policy Number. <br /> I certify(hat in the performance of the work for which this permit is issued, I shall not employ any person in <br /> �_ ��m'co•nr nantion Laws of California, and agree that if 1 <br /> shout be me subject to the wcrlr-" --""''-,;inn provisions of Section 3700 of the Labor Code. I shall <br /> forthwi mplywith those provisions. <br /> 1 <br /> Dater i _,Signature: 4e4--4u-1- e 2e <br /> Printed Name: r �L <br /> WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,A D SHALL SUBJECT <br /> Ay sNn Cnfli-FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> (5100,000.),IN ADDITION TO THE COST or COMPFNSATION,(NTEREST,ATI-ORNEY'S FEES,ANu DAMAGtt+,Ic <br /> PROVIDED FOR iS ECCT70R S7nc OF TH9 I.egnR CADF. <br /> THJORIZATIO FOR OTHER THAN C-67 SIGNING PERMIT APPLICATION <br /> ig .t re�ofCC-S7�)lliican d au h nzdd mems nta�tiQ (I !� <br /> hereby authorise(print name) <br /> to sign thio San Joaquin County well Permit Application on my behalf. I understand chi*outhorizatloh is valid fns <br /> one(1)year apd Ie Ilmited to the work plan datoni on fhck frord page Of this application. <br /> 0.29-02 1 MI <br />