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06/20/2000 09:52 2094683433 FIFTH FLOOR PAGE 03 <br /> VOW <br /> San Joaquin County Environmental Health-Services, Unit IV Well Permit Application Supplement ' <br /> JOB ADDRESS:_ men(&4ciyy) �W 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 Division <br /> 3 of the Business and Professions Code and my license is in full force and effect. <br /> License#: 4 D S q a, �' Expiration Date: J ' 3 bb <br /> Date: (e OD Contractor: �� l P�o►'��C <br /> Signature: Title: tA <br /> LSA-�C,e� C71/�1D4 <br /> s <br /> Printed name: <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the following declarations: (CHECK ALL THAT APPLY) <br /> _l have and will maintain a certificate of consent to self-insure for workers' compensation,as provided for by <br /> Section 3700 of the Labor Cade, 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 policy numbers are: <br /> Carrier: )pS Policy Number:N LUIJA`J 1 3 19 CIO 1 <br /> I certify that in the performance of the work for which this permit is issued. l 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, l shall <br /> forthwith comply with those provisions. <br /> Date: Signature: <br /> Printed Name: <br /> WARNING: FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> PON SECTION 37 6 OF THE LABOR <br /> $ <br /> ROVIDED ADCOMPENSATION,INTEREST,ATTORNEY'S FEES,AND DAMAGES AS <br /> I. fl (C•57 licensed authorized representative),hereby <br /> authorize <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 />