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02/08/2001 14:23 2094,1118 AGE STOCKI"ON PAGE '= <br /> 3 <br /> San Joaquin County Environmental Health Servlr_es,Unit IV Well Permit Application Supplement <br /> JOB ADDRESS. -7(A E •C .k Work PERAAtT 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#: Ile b te Expiration Date: <br /> Date: 1 n Contractor <br /> Signature: <br /> Printed name: ryl rA <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm under penalty of p6dury one of the following declarations- (CHECK ALL THAT APPLY) <br /> I have and will maintain a certificate of consent to self-Insure for workers' compensation, as proWded for by <br /> 71have <br /> ction 3700 of the Labor Code,for the performance of the work for which this permit Is issued. <br /> ✓ and will maintain workers'compensatiotl 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'compensatton insurance <br /> carrier and policy numbers are' I ,�nr, <br /> Carrier: ✓�QQ a�k I' r`��t' Policy Number: 1k)C, ✓) S <br /> _ I certify that In the perf Arica 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 California, and agree that if I <br /> should become subject to the workers' compensation provisions of Section 3700 of the Labor Code, I shall <br /> forthwith co( I <br /> m�plywith those provisions. <br /> Date: cAb D) Signature: <br /> Printed Name: 1 r � � <br /> WARNING:FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FlNe3 UP TO ONE HUNDRED THOUSAND DOLLARS <br /> ($IGo,000.),IN ADOMON TO THE COST OF COMPENSATION,INTEREST,ATTORNEY'S FEES,AND DAMAGES AS <br /> PROVIDM FOR IN SECTION 3705 OF THE LABOR COME. <br /> i, <br /> (C-til licensed authorized mpmsentathre),hereby <br /> authorizo lt1\ s1 <br /> to sigh this San Joaquin County Weil Permft Application on my behaN. I understand this authorization is vaild for <br /> one(1)year and In limited to the work plan,dated on the front page of this application. <br /> 5-117,20041 IMI <br /> �!� a6e�i `•ZE EI l0 6 Qat `.ZOEO ElE SZ6 `• 'out `bUTTSal 8 6utTTTJo 660u0 .Ae }UaS <br />