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San Joaquin County Environmental Health Department Unit IV Well Permit Application Supplemental <br /> JOB ADDRESS: AAW /6 SW e— d,y p e/t'/,E PERMIT SR# <br /> G.r'r9,to� c,,eF- 95"33v <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> i <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#: locS4 $ Exp Date: 5-3l-Zoo°Ipp <br /> Date. kk 10.0 Contractor. Ti -(- �)oujl h�'o. ;;Oyv,� <br /> Signature: 'l Title: KMO <br /> Print Name: Ne+�nu Q (l�i�k+vtio� <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 carder and policy numbers are: <br /> Carrier: S1►aT�- Policy Number: Ucc)6CS3--Am& <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: <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 3906 OF THE LABOR CODE. <br /> AUTHORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> I, _ (signature of C-57 licensed authorized representative), <br /> hereb authorize(print name) <br /> !&,'KfPD NE�r/�iA fT lEt �aw5acrra6� 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 /> RI2A/02fM1 <br /> EHD3 01115 7 WELL.PfRMR MP <br />