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San Joaquin County Environmental Health Department Unit IV Well Permit Application Supplement <br /> JOB ADDRESS: /7'wGU. _ PERMIT SR#: Dti34� <br /> A Rn �,.. ►eo ►�% . .. °N:?09 -;0�9 <br /> CC N--T�TL L,uS <br /> LICENSED CONTRACT RS DECLARATION (LCD) <br /> I hereby affirm that I am licensed under the provisions of Chaptor 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#: 33—/ Expiration Dater )l�(S <br /> Date: Contractor: D r�L L 1 <br /> Signature: Title: ..V i <br /> Printed name: �G <br /> WORKS 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 provided for <br /> by 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 <br /> ----policy numbers are: I <br /> Carrier: �T�ttT.i.0 —pty-1-A 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 3700 of the Labor Code, I shall <br /> forthwith comply with those provisions. <br /> Expiration Date: Signature: <br /> Printed Name: t + <br /> WARNING: FAILURE TO SECURE WORKERS' COMPENSATION CO AGE 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 /> l (signature ofC-57 licensed authorized representative), <br /> hereby authorize(print 4e) Lkrzj�Y S <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/MI <br /> EHD 29-02-001 <br /> 6/22/04 <br />