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FIFTH FLOOR <br /> — . PAGE 03 <br /> San Joaq <br /> unty Envirb�Health Ser—vices,- -� <br /> JOB ADDRESS: u <br /> mt IV Well_Permit pq plication P ement <br /> PERMIT`SR#: <br /> LICENSED CONTRACTORS DECLARATION <br /> I hereby affirm that I (�� <br /> 3 of the Business and licensed under the <br /> Professions Code and rovisions of Chapter 9 <br /> / �� my license is in full force with Section 7000 <br /> License#: (J and effect. <br /> Of Division <br /> Date: Expiration Date: <br /> Signature: l, <br /> ContraC�r• �02 <br /> �\c����\ <br /> Printed nave: fie' S tf <br /> WORKERS, COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the following declarations: (CHECK ALL THAT APPLY) <br /> _I have and will maintain a certificate Of consent to self-insure for workers'compensation, as provided for by <br /> Seckon 3700 of the Labor Code, 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 ate performance of the work for which this permit is issued. My workers'compensation insurance <br /> varier and policy numbers are: <br /> Cartier. Policy Number. <br /> 1 cerify that in the performance of the work for which this permit is issued, I shall not employ any person in <br /> any manner so as - become subject to the workers'compensation laws California, and agree that if I <br /> Should become subject to the workers'compensation provisions of se io 700 of the Labor Code, I shall <br /> forthwith corn ly with those provisions. <br /> Date: CO Signature: _ `\ <br /> Printed Name: 61j� 4A,vrlr`(( <br /> WARNING: FAILURE TO SECURE WORKERStCOMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES ANS CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> ($100,000.), IN ADDITION TO THE COST OF COMPENSATION,INTEREST, ATTORNEY'S FEES,AND DAMAGES AS <br /> PROVIDED FOR IN SECTION 3706 OF THE LAVR CODE. <br /> 1, (C-57 licensed authorized representative),hereby <br /> authorize <br /> to sign this San Joaquin County Well Permit)plication on my behalf. I understand this authorization is valid for <br /> one(1)year and is limited to the work plan dad on the front page of this application. <br /> 1 <br />