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r <br /> San Joaquin County Environmental Health Department Unit IV Well Permit Application Supplement <br /> JOB ADDRESS: 1333 F4 l PERMIT 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 fill force and effect. <br /> License#: ���` �5`1 b Expiration Date: i 3 ► oCa <br /> Date: l Is 1 C-)41Contractor: <br /> Signature: Title: <br /> Printed name: <:: l -t-s tom£ <br /> WORKERS' COM PENSATIO N 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 provided for <br /> by Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. <br /> ✓I have and will maintain workers' compensation 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'compensation insurance <br /> carrier and policy numbers are: <br /> Carrier:- �'�'Y��!-� 1 1�5 Policy Number: T�L�1C7�O� CQ <br /> I certify that in the performance of the work for which this ermit is issued, I shall not employ any person in <br /> any manner so as to become subject to the workers' compensation laws of Califomia,and agree that if I <br /> should become subject to the workers'compensation pro isions of Section 3700 of the Labor Code, I shall <br /> forthwith comply with those provisions. <br /> Expiration Date: Signature: ` <br /> Printed Name: C.KeA-S gAS <br /> WARNING: FAILURE TO SECURE 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 THE COST OF COMPENSATION,INTEREST,ATTORNEY'S FEES,AND DAMAGES AS <br /> PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. <br /> AUTHORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> I, <br /> _(signature ofC-57 licensed authorized representative), <br /> hereby authorize(print name) <br /> to sign this San Joaquin County Well Permit Application on my behalf. I understand this authorization is valid for <br /> one(1)year and is limited to the work plan dated on the front pzz ige of this application, <br /> 8-29-021 M <br /> FHD 29-02-001 <br /> 9/30/2043 <br />