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¢�Y13/2001 08:36 20946P'433 FIFTH FLOOR rrte,l PAGE 03 <br /> L <br /> San Joaquin County Environmental Health Services,Unit IV Well Permit Application Supplement <br /> ii <br /> JOB ADDRESS. �wU �Zi_�' o U—lay PERMIT SR#: 2teq34 <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> l i <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 Code and my license is in full force and effect. <br /> License#: �"6� s f'ZZ.C¢� C Expiration Date: �1.30i•200 3 <br /> S <br /> Date: 1 Contractor: pGe,41- Mg t✓jc pJJtovw,�7 , 1�I C• <br /> Signature: Title: <br /> Printed name: (l11 <br /> i <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 /> 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 <br /> are: <br /> Carrier: AmyillsM Ao6y4 tKL. 11. Policy Number: 5BGOSs75800 <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 become subject to the workers'compensation provisions of Section 3700 of the Labor Code, I shall <br /> forthwith comply with those provisions. <br /> Date: 1 Signature: IAIA <br /> T I'^ <br /> Printed Name: (S'\ Ni v <br />( WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT <br /> i AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> ($100,000.),IN ADDITION TO THE COST OF COMPENSATION,INTEREST,ATTORNEY'S FEES,AND DAMAGES AS <br /> PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, <br /> d <br /> I, tM IL�PtlVt}Q.� ^.("T licensed authorized representative),hereby <br /> i <br /> authorize 1 -e-LSVttLeiTS <br /> to sign thisSan Joaquin County Well Permit Application on my behalf. I 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 /> j 5-17-2000/MI <br /> 1 <br /> 3 <br />