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San Joaquin County Environmental Health Department Unit IV Well Permit Application Supplemental <br /> i <br /> JOB ADDRESS: 1550 Industrial Drive, Stockton, CA 95206 PE RMIT SR # <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> i <br /> I <br /> I hereby affirm that I am licensed under the provisions of Chapter 9 +,commencing with Section 7000) of j <br /> Division 3 of the Business and Professions Code and my license is in full force and effect`. <br /> License # 705927 E xp Date. 1 <br /> /1 <br /> Date `t Cl- Contractor Vironex <br /> 'i <br /> Signature Title <br /> g � ' � CH ' r <br /> Print Name c <br /> I <br /> WORKER'S COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the following declarations. (check one) <br /> vbyI have and will maintain a certificate of consent to self-insure for workers' compensation. as <br /> provided for by section 3700 of the labor Code, for the performance of the work for which this <br /> permit is issued <br /> I have and will maintain workers' compensation insurance. as required by Section 3700 of the <br /> Labor Code, for the performance of the work for which this permit is issued. My workers' <br /> compensation insurance carrier an d policy numbers are <br /> Carrier: e'� ) J, Policy Number: I_ ,I Q (1 <br /> I certify that in the performance of the work for which this permit is issued, I shall not employ any <br /> person in any manner so as to become subject to the workers' compensation law of California. and <br /> agree that if I should become subject to workers' compensation provisions of Section 3700 of the <br /> Labor Code, I shall forthwith comply with those pro inions. <br /> Exp. Date: OR, Signature: 1 L I lel C }� <br /> Print Name: n o uL.n1ri 1111 n,,r t t <br /> WARNING'FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT AN EMPLOYER TO <br /> CRIMINAL PENALTIES AND CIVIL FINES UP TO 5100.000,IN ADDITION TO THE COST OF COMPENSATION,INTEREST, <br /> ATTORNEY'S FEES,AND DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE <br /> AUTHQRIZA,TION FOR THER THAN C-57 SIGNING PERMIT APPLICATION <br /> I, I (signature of C-57 licensed authorized representative), <br /> hereb authoril I(print name) Alma Quezada to <br /> sign this San Joaquin county Well Permit Application on my behalf. I understand this authorization is valid <br /> for one year and is limited to the work plan dated on the front page of this application. <br /> R/?9rn?/MI <br /> EHD 2MI 11W7 Y:cLL PEPWT AaP <br />