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San Joaquin County Environmental Health Depart.. <br /> nt Unit#V Well Permit Application Supplemental <br /> JOB ADDRESS: �� <br /> ' 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 oftheBusiness and Professions Code and my license is in full force and a ct. <br /> License[#: 6 09 0q:: D <br /> i Q (�� Exp Date: <br /> Date: Contractor: <br /> Signature:L Title: <br /> Print Name: , <br /> I <br /> WORKER'S COMPENSA N DECLARATION <br /> I hereby affirm under Penalty of Perjury one of the following declarations: (check cine) <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 /> Kermit is issued. <br /> -11....1 have and will maintain workers'cern <br /> pensation Labor Code,for the Performance of the work for which this as <br /> is isslbled eMIRC 3700 of the <br /> Compensation insurance Carrie and policy numbers are: p y workers' i <br /> C;1�rrier.�1! <br /> Policy Number: -" <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 /> Label Cod , I shall fiarthwith comply with those provisi ns. <br /> Exp. Date: (L) �/ ' <br /> � Signature: <br /> Print Name: �, �� <br /> t�(� �r AM <br /> WARNING,FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE is UNLAWFUL,,AND SHALL SUBJECT AN <br /> CRIMINAL PENALTIES AND CML FINES LIP TO$144,000,IN ADDITION TO THE COST OF EMPLOYER TO cc�rneNswTror�,rrrrER�sr, <br /> ATT ORNEY'S FEES,ANDDAMAGES AS PROVIDED FOR IN SECTION 3708 OF TETE LABOR CODE. <br /> R OTHER THAN C-S7 SIGNING PERMIT APPLICATION <br /> (sigriature of C-57 liegnseyd authorize)representative), <br /> hereby authorize(print name) to <br /> sign this son Joaquin county Well Permit Application an my lrelralf. I un eTstanst this authorization is valid <br /> for one year and is limited to the work plan Meted on the front page of this application. <br /> RE2M <br /> EMD 24111 115.67 <br /> WELL PEWTAPP <br />