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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 Business and Professions Code and my license is in full force and effect. <br /> License#: g a 3 3 -I Expiration Date: 13 1 - 03 <br /> Date: q - I -?- / /U�L1M-lA�L)3 Contractor: `u(�_(77 SO t3Q NCj a N I G 101 <br /> 1 /CNi <br /> Signature: h AlPC Title: V� P <br /> Printed name: -b6 N Lk) I N 4�£W l L� <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 /> by Section 3700 of the Labor Code,for the performance of the work for which this permit is issued. <br /> V/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 /> Carrier: t. o"E2 /n <br /> 5 C OMI 'FLA-pb. Policy Number: <br /> 1 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 700 of the Labor Code, I shall <br /> forthwith comply with those provisions. <br /> Date: T-17-03 Signature: <br /> Printed Name:./(�J de 00 <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 FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> *M im 41it1A))'(ph <br /> 1 (signature ofC-57 licensed authorized representative), <br /> hereby authorize(print name a I 1 - ) I L,p.r-tR K\e�- <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 />