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San Joaquin County Environmental Health Services,Unit IV Well Permit Application Supplement <br /> JOB ADDRESSA- O 4ruC/U-b PERMIT SR#: <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> 1 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 full force and effect. <br /> License#: /UIExpiration Date: <br /> Date: _(J 00 ontractor: - <br /> Signature: (( Title: <br /> Printed name: d1 n <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the following declarations: (CHECK ALL THAT APPLY) <br /> _I have and will maintain a certificate of consent to self-insure for workers' compensation, as provided for by <br /> Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. <br /> V/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_5a__��J�,�,! <br /> mg- ) - Policy Number: <br /> �C <br /> _I certify that in the performance of the work for which this permit is issued, 1 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 become subject to the workers'compensation provisions of Secti n 3700 of the Labor Code, I shall <br /> forthwith�comply with those provisions. <br /> Date: L__ ^,"0DSignature: <br /> Printed Name: <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 /> ($10VADDITION TO T14E COST <br /> SECTION 37 6 OF THEFtCOMPABORENSATION,INTEREST,ATTORNEY'S FEES,AND DAMAGES AS <br /> PROVIDED OR <br /> (C-57 licensed authorized representative), hereby <br /> 1, <br /> authorize <br /> to sign this San Joaquin County Well Permit Application on my behalf. 1 understand this authorization is valid for <br /> one(1)year and is limited to the work plan dated on the front page of this application- <br /> -A 0 <br /> pplication.dn J-i t^JVTS 6 l 666 l—P�—i�1. <br />