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San Joaquin County Environmental Health Department Unit IV Well Permit Application Supplement <br /> _ JOB ADDRESS 1510 F NAiE L1014 AVS Sul;t,3oN PERMIT SR#: <br /> I <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# L 5 / - -7/00 -2t-- _ Expiration Date r7dS— <br /> Date ? D S Contractor <br /> Signature <br /> ~ Title <br /> Ir Printed name v n�Gi h1 Cr - 4 <br /> 11 WORKERS' COMPENSATION DECLARATION <br /> ` I hereby affirm under penalty of perjury one of the following declarations (CHECK ONE) <br /> f _ I 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 /> 14-1 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 <br /> _ Policy Number L� a a <br /> Carrier 3 <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 /> � <br /> i � - <br /> ' Expiration Datef O 16 __ Signature --------- <br /> Printed Name'_CJn�/N�r_ _J4�[Gl2l_�L ��=�----------------_------- <br /> WARNING <br /> FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE iS UNL-AWFUL,AND SHALL SUBJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CML FINES UP TO ONE HUNDRED THOUSAND DOLL <br /> ARS <br /> ,IN ADDITION OF COMP CODEION,INTEREST,ATTORNEY'S FEES,AND DAMAGES AS <br /> PROVIDED ORIN SECTION 3706 O T <br /> AUTHORIZATION FOR OTHE_RTHAN C-57 SIGNING PERMIT APPLICATION <br /> I i <br /> (signature ofC-57 licensed authorized representative), <br /> hereby authorize(print name) 1 4 S I p N A M (r <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 1 MI <br /> EHD2902001 <br /> 6122/04 <br />