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San Joaquin County Environmental Health Department Unit IV Well Permit Application Supplement <br /> JOB ADDRESS: PERMIT SR#: <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 Businessand ProfessionsCodeC1ode and my license is in full force and effect. <br /> License#: Vv a� ✓ �'r Expiration Date: LI <br /> Date: `I t/ Contractor: Y7�Q� 1 C ` / <br /> Signature: Title: t/ <br /> Printed name: <br /> WORKERS' 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 provided for <br /> /bbl 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: r c� <br /> Carrier: �ko A(( Policy Number: 1 LP c > s 0 <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: q-623— d-3 Signature: //'' l <br /> Printed Name:0&OA�L A / <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 /> AUTHORIZATION 'F\OR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> L� (��,� /� (signature ofC-57 licensed authorized representative), <br /> hereby'-authorize(prin�) <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 /> 8-29-021 MI ._ <br />