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i moo . <br /> San Joaquin County Environmen I Health D partment Unit IV Well Permit Application Supplemental <br /> JOB ADDRESS' <br /> J �PERMIT SR# ©5 <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> 1 <br /> ( I hereby affirm that I am licensed under the provisions of Chapter 9 (commencing with Section 7000) of <br /> 1 Division 3 of the Business and Professions Code and my license is in full force and effect. <br /> License#: $51( Exp Date: 6 <br /> Date: Contractor: r <br /> Signature: Title: <br /> Print Name: OaY��bot�!L IV nay— <br /> WORKER'S <br /> lf —WORKER'S COMPENSATION DECLARATION <br /> I 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 /> i <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: 13�tk, Policy Number: �FJ�o$0& <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 provisio S. <br /> Exp. Date: JSI[20� Signature: <br /> Print Name: �p <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 /> J�fIIN FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> I, 7. <br /> (signature of C-57 licensed authorized representative), <br /> hereby aut orize(print name) 5f—Ylh IV R-412l e5 <br /> 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 /> EMO 28-01 11/5107 <br /> WELL PERMIT APP <br />