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09/19/2008 10: 42 7073740 WCQDWARD DRILLIA PAGE 01/01 <br /> V' ,Um� � �o r/ <br /> [ San Joaquin County Environmental Health Department Unit IV Well permit Application Supplemental <br /> JOB ADDRESS: �s re ADth�o s>' sJey CAaP PERMIT SR# P/t/J��J 6 <br /> 1 <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> I hereby affirm that I am licensed under the provisions Of Chapter 8(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 M ? / 00 2 LY _ Exp Date: 6 9 <br /> Date: / fi Contractor: rJb LtJ <br /> 'Itr�o .DIcICy.f ..,c Com.-�7J <br /> Signature: �uitte: /1e G4 eQa. <br /> U 19 <br /> Pr€nt Name: (!,0NC-1 W 6 C _ W CK,D I-V q ce0 <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 <br /> n�insurance <br /> 11carrier and policy numbers are: <br /> Carrier; e-zC �i w� 6( Policy Number: Q a-0 a- g <br /> I certify that In the performance of the work for which this permit is issued, I shalt 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: 7 °! ° Signature:et it v <br /> Print Name: NC UG A WJV0k1A-R <br /> WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT AN EMPLOYER TO <br /> CRIMINAL PENALTIES AND CML FINES UP To$100,0000,IN ADDITION TO THE COST OF COMPENSATION,INTEREST, <br /> ATTORNEY'S FEES,AND DAMAGES AS PROVIDED FOR IN SECTION 3708 OF THE LABOR CODE, <br /> AUTHORIZATiOOR OTHER THAN GS7 SIGNING PERMIT APPLICATION <br /> I' °� not re of C-57 licensed authorized representative), <br /> hereby authorize(print name) <br /> r .1c, <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 /> 8/29102fM1 <br /> EHO 4801 717bg7 <br /> YWLLP5WFAPP <br />