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-o- p,9 �T, eyCS <br /> San Joaquin County Env ronmental Health Department Unit IV Well Permit Application Supplement <br /> JOB ADDRESS: PERMIT SR#: <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> 1 hereby affirm that I am licensed under the provisions of Chapter 9 (commencing with Section 7000)of Division <br /> 3 of the Business and Profesi ions Code and my license is in full force and effect. <br /> License#: Fo,03 3 Expiration Date: h:9 <br /> Date: Jr OContractor: P317(Dr iL� <br /> Signature: I Title: , f J NL ZnT <br /> Printed name: f✓l G� <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm under penalty 3f perjury one of the following declarations (CHECK ONE) <br /> _I have and will maintain certificate of consent to self-insure for workers' compensation, as provided for <br /> by Section 3700 of the L ibor Code,for the performance of the work for which this permit is issued. <br /> 1 have and will maintain orkers'compensation insurance, as required by Section 3700 of the Labor Code, <br /> for the performance of th work for which this permit is issued. My workers'compensation insurance <br /> carrier and policy numbe s G7- are: <br /> J <br /> Carrier: JI ' \l PolicyNumber.--M:j1` A-710a <br /> I certify that in the perfor nance of the work for which this permit is issued, I shall not employ any person in <br /> any manner so as to be me subject to the workers'compensation laws of California,and agree that If I <br /> should become subject t the workers'compensation provisions of Section 3700 of the Labor Code, I shall <br /> forthwith comply with the a provisions. <br /> Expiration Date: to Signature:, <br /> Printed Name: t <br /> WARNING: FAILURE TO SECL RE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> ($100,000.),IN ADDITION TO I HE COST OF COMPENSATION,INTEREST,ATTORNEY'S FEES,AND DAMAGES AS <br /> PROVIDED FOR IN SECTION 1706 OF THE LABOR CODE. <br /> ALITHORIZATIOl I FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> t A (signature ofC-57 licensed authorized representative), <br /> hereby authorize(print name) / <br /> to sign this San Joaquin Cour Well Permit Application on my behalf. I understand this authorization is valid for <br /> one(1)year and is limited to I is work plan dated on the front page of this application. <br /> 8-29-021 MI _ <br /> F14D 29-02-001 <br /> 6122104 <br />