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04,'24/2003 THU 08:25 FAX (11u2 <br /> San Joaquin County Eytvironrrter+.tai Health Serrtce,4,Unit IV V1leii Permit A;.plia0tior+Sypptement <br /> SOB ADDRESS: � , 7 <br /> PERMIT SRO: i <br /> LICENSED CONTRACTORS E)ECLARATION (LCD) <br /> I hereby ?ffirrn that I cm iicens•.d unrier:he provi3ions of Chapter 9 (CuMMencing with Section?0QU)of Lei`,Ision <br /> 3 of vie Business and Pro`essions Clx7e and my iicense is in full force and effect. <br /> Ucense#-. .. 'T95 r Expirat+on nate; <br /> �74 0.3 ontraor: I �. C <br /> C7ate:_ 1� r <br /> � Title' <br /> Signature:— <br /> V r. <br /> Printed name: 0 f -� <br /> WORRIERS' COMPENSATION DECLARATION <br /> I <br /> I 1 beret f affirmunder panaih ref por;sry one of t Ic followi^y ducrarat3ons: (CHECK LLL THAT APPLY <br /> 1 I nr3ve and vdill maintain a certific-ate of consent to self-Insure for wortcars' con',Pensaiio,�, as provided fur by i <br /> Section 3700 of:he Labor Coda,for the rfocmanG o`the worK for wh ch this permit is issu, d. <br /> s <br /> ✓ I Neve and will maintain WoMer.;'conlpen3.�tion tnsur3nee,as nryquirer! by u�-Cb+7n 3700Gf ih2 Labor Gods, <br /> —for the performance of the work for which this Permit's <br /> issued. My erorkrr5' c�ompegZsation insur<;nce <br /> carrier an0 policy numbers are: <br /> Calmer: U ' _ _poiicy Number: i <br /> >, f It'$work for which this permit is issued, i shsi!n0,emooi any parson In <br /> t cartiSy!hat ;r.+„�pErtormance o � <br /> any manner:sv as to become sLibjact to tie workers'cornpensation laws of California,ano agree that it 1 <br /> should G, come subject to the vvorkers' cornpensatio"provisions cf Section 3700 of the Labor Code, 1 s!-NI <br /> forthWitt)Compty%vita those pr4v1saon$. { . <br /> Date.—: ' Z C 3 -Signature: -- <br /> PrUnted Name:._ <br /> 'WARNING: FAILURE TO SECURE WORKERS'COMFENSATION COVEP2A(aE lS UNLAWFUL,AND SHALL SUBJECT <br /> Am EiijiFLOYI:R TO CRIMIgAL pr-.NAI-TIES AND Ci`:iL FINES UP TO ONE HUNDRED THQUSAND DOLLARS ` <br /> ($t0o,0o0.), IN ADDMON TO THE COST Or COMPENSATION,!!dT�REST,ATTORNEYS FEES,AND DAMAGES AS <br /> PROVIDED FOR 1"SE0710N 3705 OF THE LABOR CODE. <br /> A. ,^(CST liccrrsee airtherrzad rspresEntative), f3erebY j <br /> autiaarize_ <br /> to sign this San Joagui-,Gounty Well Permit ApPlic-ation qn my t3chalf. I understa,'1d this y,uthoriz:aticn is vaiid for <br /> 1' ear an(.is itmitod to thU we ri(plan dated on titre from:pang o`this application. _ .J <br /> --- <br /> 0me <br />