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�jvvs <br /> �I <br /> an Joaqut^CouhtY Envirrr►r+ner►ti►1 Health Services,,l!ntl IV Well Permit Appllcetion$uppteme^t <br /> �3(a •Pr-FtMIT' SR##: ' <br /> JOEADDRESS:,—.-,�_..___.. <br /> LICENSED CONTRACTORS DECLARATION ( .R) <br /> I hQ by affirm that)*in lioensed under the provisions of Chapter 9(comrnencirg with Se cation 7000)of D!vislon <br /> 3 Of the Business and Professions Coda and my license is In full force and effect. <br /> / Expiration Date:. <br /> l.iCensa#: <br /> Date: "' � _�rontractor – <br /> f - <br /> $19nature: <br /> Printed name:,,�_c _1�t..^V) 1 �� <br /> WORKERS'COMPENSATION DECLARATION <br /> 1 hereby affirm under penalty of per)ury one of the following dAclaratlons• (CHI=CK ALL THAT APPS <br /> I <br /> I have and will maintain a certiflesta of consent to sect-Insure for workers` compensation, as provided for by <br /> Section 3700 of the UibDr C O&,for the perforrmnce of the work for which this permit>i issuea. <br /> I have and will maintain workers'eprrrpensa(ion Insurance,as required by Seotlon 5700 of the Labor Godo, <br /> �- for tate p9rform1AnC8 of the work for which this permit is issi.ieci. MY workers'CornQgnsaUon insurance <br /> carrier and policy numbers are: <br /> Carrier: .r�-��- Policy Number: - <br /> I certify that In the petformanae of the work for whioli this parmlt Is issued,t shall not employ any person in <br /> any manner so as to become svbJea to the workers'compensation laws of California, and agree that if I <br /> shoved n ner so sato to the wrorkers`compensation provisions of gel�ltion 3700 of the Labor Coda, I shall <br /> forthwith Fomply with those provisions. <br /> Onto: '�� ' y Stynature <br /> Printed Noms'— �--- <br /> UL,AND SHALL <br /> WAR AN �tpO�R O CRIMINAL PENALTIES ANO CIVIL F HeS UP TO ONE HUNDRED THOUSAND POLLARSUBJECT <br /> ($100,000.) IN <br /> FOR ISECTION 3706 CDITION TO THE COST N Of THE LABOR CODE.ON,lNTEREBT,ATTORNEY'S FEES,AND DAMAGES A9 <br /> PROYi <br /> ilea ct:uthoriud roprvvent ties, izorepy��r <br /> � n .�� L l tVf <br /> to vign this San Joaquin County Well Permit Appil"00n on my behalf. t understand this autnoftzation ix valid toy <br /> arta ifr end is Ilrnite0 to the wee,rk pian <br /> 1e!Lori the front p*SO of fhf*• tfoation. <br /> r <br />