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San Joaquin County Environmental}iealth De rt ent Unit IV Well Permit Application Supplement <br /> 2�9`f F• f �ov"� <br /> 09 <br /> JOB <br /> JOB ADDRESS: C Z`/S/ v;• /2erxrwtS��>( � PERMIT SR#:-o0 <br /> LICENSED CONTRACTORS DECLARATION LCD <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 #: C I �A t)SUDS Expiration Date: I/-_�p <br /> Date: II I Di <br /> c. <br /> Signature: v� Title: 1�fif� Yrr�r1�C�2 <br /> Printed name: CY11 1�7�pl lE"�1�1�nPr <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the following declarations: (CHECK ONE) <br /> X' have and will maintain a certificate of consent to self-insure for workers' compensation, as provided for <br /> by 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 are: 2 2 <br /> Carrier: cq " \ Policy Number: C L�,l J?J0'?)2"l'-_) <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: IO/'�JI 1OZ Signature: ` � -- <br /> Printed Name: coy lat_y f 1^Ie1­- Pr )ne - <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 /> ($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 /> AUTHORIZA ION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> 1 , (signature ofC-57 licensed authorized representative), <br /> hereby authorize (print name) <br /> to sign this San 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 /> 8-29-02/MI <br />