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,d� . . i <br /> !✓�I/L �'a� 5731 <br /> San Joaquin County Environmental Health Department Unit IV Well Permit Application Supplemental <br /> JOB ADDRESS: 1461/ ��-�`�� (PERMIT SR# e9���ti7J6 r <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#: `lA (0671 Exp Date: <br /> Date: Contractor:l)QQ .DW-A j)!C 1AYN 21 <br /> Signature: 1�°A/v\4 ' .u')&Q&JtAJ Title: <br /> Print Name: 61 ci m )t, JL <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 insurance carrier and policy numbers are: <br /> Carrier:Eka Policy Number: Qu aCO-51 <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, I shall forthwith comply with those provisions. <br /> Exp. Date: (7 – L� Signature:e9aMc1. `l 1 I� ,�Si?► <br /> Print Name:�NM\1.tVv �_ <br /> — Q <br /> WARNING:FAILURE TO SECURE WORKERS'COMPENSATION GE IS UNLAWFUL,AND SHALL SUBJECT AN EMPLOYER TO <br /> CRIMINAL PENALTIES AND CIVIL FINES UP TO 0,000,IN ADDITION TO THE COST OF COMPENSATION,INTEREST, <br /> ATTORNEY'S FEES,AND DAMAGES AS VIDED FOR IN SECTION 3706 OF THE LABOR CODE. <br /> AUTHORIZATION OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> I, (signature of C-57 licensed authorized representative), <br /> hereby authorize(print name) %MLA� ,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 /> 91291021MI <br /> EHD 29-01 11IM7 WELL PERMIT APP <br />