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San Joaquin County En ronmcntai Health 3�7av <br /> Icis.Unit IV Well Permit ApplicatfArt Su_pts,,ment .-.-. <br /> JOB ADDRESS:_ � PERMIT SR#:_ <br /> i <br /> f <br /> LICENSED CONTRACTORS DECLARATION (LC©) <br /> 1 hereby zffimi that)arc rcensW finder fro proviaicrs of Chapter 9(commencing with Section 7400)of Division <br /> 3 of the Business and Professions Cade and my 11cense is in full forca and effect. <br /> AEx iraticxr 02fe- 3 <br /> 1 Date_ 7 Contractor% J <br /> ` Signature: {y' Title: I EN <br /> Printed name. <br /> WORKERS'COMPENSATION DECLARA7' N <br /> i <br /> I hereby affirrn under penalty of perjury one of the following dett-taretions- (CHECK ALL THA7 APPLY) <br /> _ f <br /> ' 1 have and will rrk?inta;n a nrtl£�cats of consent to self-insure for tivoricers'ecWnpensation,as provided for by 1 <br /> SaaUon 3700 of tho tabor Code,for the performance of tha work for which this permii is Issued. <br /> 1 I have and will maintain werxers'compensation insurance,as required by Section 3700 of the Labor Gone, <br /> for the performance of the work for which tfiis acnnit;s issued. My workars'compensation insurance <br /> corner and palic numbers are: <br /> Carrier- polity Number. t t <br /> I certify that in the performance of the work for which tljis permit is issued, I shall not employ any,person in <br /> any manner so as to becofre sutlect to the workers'oompent*tion jaws of California, and agree that If 1 <br /> shautd become subject to tlia Hackers'cormQens3con provisions of Section 3700 of the Labor Code,t snap <br /> forthwith comply with those provisions. <br /> (Sate: Signature: _ <br /> Printed N2i'ns: <br /> WARNING: FAILURE TO SECURE WORKERS'COMPENSATtON COVERAQE 19 UNLAWFUL,AND SHALL S1.18JECT <br /> AN EMPLOYER TO CR MINAL PENALTIES AND CIVIL FINES UP rO ONE HUNDRED THQUSAHD DOLLARS <br /> 3100,000.),IN ADDITION TO THE COST OF COMFI"NSATION, INTEREST,ATTORNEY's FEES,AND DAMAGES AS <br /> PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. <br /> authorize- — P141,14 <br /> t, � 61��1(G L P-1 / (C-57 ttcensed euthorrzQa represcntativR),henc�y <br /> I to sign this Sari Joaquin County Well Permit,4p0catlon on my behalf. I understand this avthoritatlen is valid fol <br /> ono(1)year and Is limited to the work Aran dated on tho front page of this app:lcation, <br /> 5.17,2000 1 MI <br />