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6AI <br /> San Joaquin County Environmental ealth Department Unit IV Well Permit Application Supplemental <br /> JOB ADDRESS: 7SO G{/ PERMIT SR# <br /> 1 <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> I hereby affirm that I am licensed under the provisions of Chapter 9 (commencing with Section 7000) of <br /> Division 3 of the Business and Professions Code and my license is in full force and effect. <br /> License#: T Exp Date: 4 <br /> Date: . __ Contractor: 1 - <br /> Signature: Title: <✓ 1�'`eS� ' <br /> Print Name: <br /> WORKER'S COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the following declarations: (check one) <br /> I have and will maintain a certificate of consent to self-insure for workers' compensation, as <br /> provided for by section 3700 of the labor Code, for the performance of the work for which this <br /> permit is issued. <br /> _I have and will maintain workers' compensation insurance, as required by Section 3700 of the <br /> Labor Code, for the performance of the work for which this permit is issued. My workers' <br /> compensation <br /> insurance carrier and policy numbers are: <br /> Carrier: c�t� r1C� Policy Number: I 153—!�� { <br /> I certify that in the performance of the work for which this permit is issued, I shall not employ any <br /> person in any manner so as to become subject to the workers' compensation law of California, and <br /> agree that if I should became subject to workers' compensation provisions of Section 3700 of the 1 <br /> Labor Code/, I shall forthwith comply with those provisions. <br /> Exp. Date: ! /116 Signature: <br /> Print Name: <br /> i <br /> WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT AN EMPLOYER TO <br /> CRIMINAL PENALTIES AND CIVIL FINES UP TO$100,000,IN ADDITION TO THE COST OF COMPENSATION,INTEREST, <br /> ATTORNEY'S FEES,AND DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. <br /> AUTHO IZAT ON FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> (signature of C-57 licensed authorized representative), <br /> hereby authorize (print ame) ,�! c.hJ to <br /> sign this San Joaquin county Well mit App kation on my behalf. I understand this authorization is valid <br /> for one year and is limited to the work plan dated on the front page of this application. <br /> R129/02/MI <br /> WELL PERMIT APP <br /> EHE)29-01 11/5107 <br /> I <br />