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U <br /> San Joaquin County Environmental Health Services, Unit IV Well Permit Application Supplement <br /> j JOB ADDRESS : PERMIT SR#: <br /> i <br /> i <br /> LICENSED CONTRACTORS DECLARATION ( LCD ) <br /> f <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 /> i <br /> f <br /> License #: v 7c7C�Z5 Expiration Date: / <br /> i f <br /> Dat( Contractor: / <br /> Signature : Title : <br /> Printed name : <br /> W KERS' COMPENSA ION 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 armee : <br /> 4 <br /> Carrier. c c. c. « Policy Number: <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 : 57 `D ¢r Signature : � <br /> Printed Name: <br /> WARNING : FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWtUL, AND SHALL SUBJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> (51001000.), 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 /> 11 (C-57 licensed authorized representative), hereby <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 /> 5A7-2000 1 MI <br />