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P. <br /> TTN <br /> San Joaquin County Enviro me ta��h De artmenntt Unit IV Well Permit Application Supplemental <br /> omis JOB ADDRESS: Kf'PERMIT SR# A / <br /> I? �0/ f-, 4.4-Ce- <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#: $") 7 O C 5-7 Exp Date: I U 10 <br /> Date: 9f z�l a Contractor: �.vvi/ZL.Jrr►i '1h�L C'Ui+yr�2L SSOCc:C1 S <br /> Signature: _�---- Title: <br /> Print Name: 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 /> t/ 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 insurance carrier and policy numbers are: <br /> Carrier. -ke b"tcL-^`f � Policy Number: W�lZ�9 S70 SCJ <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 become subject to workers'compensation provisions of Section 3700 of the <br /> Labor Code, II sall forthwith comply with those provisions. <br /> Exp. Date: 811110 Signature: <br /> Print Name: <br /> WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT AN EMPLOYER TO <br /> CRIMINAL PENALTIES AND CIVIL FINES UP TO$900,000,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 /> --.AUTHQRlZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> I, 1 t v-%, (!I ll.4--- (signature of C-57 licensed authorized representative), <br /> hereby authorize(print name) EPtyAtJ to <br /> sign this San Joaquin county Well Permit Application 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 /> e129102/M1 <br /> ENO 29-01 115107 <br /> WELL PERMIT APF <br />