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San Joaquin County EnWronmental Health Department Unit IV Well Permit Application Supplement <br /> JOB ADDRESS: PFRMiT SR#:_ 4, 3`l 3 L-/ <br /> LICENSED CONTRACTORS DECLOATiONL( CD) <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 coce and my iicen8e is in full force and Effect. <br /> urer,se � I 1 ( © Expiration Date: �Q((� <br /> bate:—'-bs- '-O Contractor. C Lb i <br /> Signature: ^-- <br /> Title; <br /> printed name: 0- <br /> WORKERS' <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby-afnrm under penalty of perjury one of the follaMng 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 /> XI have and will maintain workers'compensation insurance,as required by Section 3700 of the Labor Code, <br /> for the partorrrlance of the work for which this permit is issued. My workers'Compensation Insurance <br /> carrier and policy numbers are: I <br /> Carrier. Polley Number. O <br /> I certify that In the performance 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 becorne subject to the mi-kers'compensatlon provisions f Sectlon 3700 of the Labor Code, I shall <br /> forthwith comply with those provisions, <br /> Expiration Dat*:5 -I - Q(p SignaturA; <br /> Printed Name- D.- Lba <br /> WARMNG;FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT <br /> AN EMPLOYER TO CRINNNAL PENALTIES AND CIVIL.FINES UP TO ONE HUN)3R£D THOUSAND DOLLARS <br /> 0100,000.),IN ADDITION TO THE COST OF COMPENSATION,INTEREST,ATTORNEY's FEES,AND DAMAGES AS <br /> PROVIDE'O FOR IN SECTION 3706 OF THE LAEOR CODE, <br /> AUTNORI lQ OR 2r?HER THAN C-57 SiGNING PERMIT APPLICATION <br /> t' (signature oftir-57 riennsed authorized representative), <br /> hereby authorize(print nam ) <br /> to sign this San Joaquin County Well permit Applicaflon on my behalf. t understand this authorization Is valid for <br /> one(1)year and is IrrmitAq to the work plan dated on the 1,mr1t page of this application. <br /> &28.021 MI <br /> 6rz2roa <br />