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San Joaquin County Envi�mental Health Department Unit IV Well P6—&Application Supplemental <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 <br /> Division 3 of the Business and Professions Code and my license is in full force and a ct. <br /> License#: - 0 q 04- <br /> Date: <br /> l <br /> ( n 1� Ex Date: <br /> Contractor: <br /> \ 40 <br /> Signature: <br /> Title: Y r-'t--• <br /> Print Name: <br /> WORKER'S COMPENSA N 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 <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 b Section <br /> Labor Code, for the performance of the work for which this permit is issued.y 3700 of the <br /> compensation insurance 5�� &-n- <br /> Policy ame and policy numbers are: My workers' <br /> Carrier: Number: '''0 <br /> 00�� r <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 Qe, I hall forthwith comply with those provi ' ns. <br /> Exp. Date; V O Signature: <br /> Print Name: f-ObY - V 1 L <br /> WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT AN EMPLOYER TO <br /> CRIMNAL•PENALTIES AND CIVIL FINES UP TO$100,000,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 /> /,/4k0THORVAT1R OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> i' (signatu of 7 licensed authorized <br /> hereby authorize(print name) ,�T11 mPentative), <br /> sign this San Joaquin county WellLalf to <br /> Pe it Application on my I undetand this <br /> for one year and is limited to the work plan dated on the front page of this app ica on atltllori2ation is valid <br /> 8r1910?JMI <br /> EM02Ui 115D7 <br /> WELL PERMfr APP <br />