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1 , 2 LlLJ E;�:4; 1d`�:?599 9 /&W DRILLIhia HAtA E L+L <br /> cA' � <br /> San Joaquin County Environmental Health D pa nR#:it IV Well Permit Application Supplement <br /> JOB ADDRESS: d�f �; PERMIT SQ/'`pl� <br /> 7 <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> I hereby affirm that i am licensed under the provisions of Chapter 9(commencing with Section 7QQQpppppp)of Division <br /> 3 of the Sueiness and Pmfessi s Code and my license is in full faros and ct• j / - <br /> 1e � ,p ✓✓✓//�J <br /> t itse#: � , <br /> Mkpiration Date: <br /> Date:, Contractor ,--� •- . <br /> Signature. f c �� f Title: <br /> f <br /> "cited name <br /> WORKERS'COMPENSATION DECLARATION � -- -- <br /> I herebyaffirm rm under penalty of perjury one of the folfowirrg declarations. (CHECK ONE) f <br /> _!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 perms is issued. <br /> I have and will rnaintain workers'compensation insurance,as required by Section 37t10 of the Labor Cade, +I <br /> for tho perforrnanoe of the work for wrhioh this permit i$issued. My workers'Compensation insurance i <br /> carrier and policy numbers are: <br /> Carrier. _ __Porky Number. <br /> I Certify that in the performance of the work for which this permit is issued, I shall not employ any person in <br /> arty manner so as to become subject to the workers'compensation laws of California,and agree that NI <br /> should become subject to the workers'compensation provisions of Sedion 37043 of the Labor Code,I shall <br /> forthwLlh cornpty wl thOIL <br /> provisions. fi <br /> 1'cxrratton Date- . <br /> p• l] �� Signature <br /> Prinked Name <br /> WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVEFtAGE IS UNLAWF ANI)SHALL SUBJECT <br /> AN EMPLOY M TO CRWAINAL PENALTIES AND CIVIL.I'm r3 UP TO ONE HUNDRED THOUSAND DOLLARS y <br /> (S7t10,000.),IN ADDITION TO T14E COST OF COMPENSATION,INTEREST,ATTORNEY'S FEES,AND DAMAGES AS <br /> PROVIDED FOR IN SECTION 3708 OF THE LABOR CODE. <br /> AUT40RIZATIGN FCR THER THAN C-57 S1GNIN-0 PERMIT APPLICATION <br /> r f <br /> (signature licensed authorized representative), <br /> hareby aukhotite(Pont name) G 6 t3Ti <br /> to sign this Un Joaquin County Well Permit Apoicatlon on try behalf, I understand this authorization is valid for <br /> one(4)year and is limited to the work plan dated on the front page of aft application. f <br /> 8-Z-02 I M1 <br /> i <br /> IItT.s 2�-02001 <br /> f 3pf2G42 -. <br />