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San Joaquin County En/vironme tal Health Services, <br /> Services, Unit IV Well Permit Application Supplement <br /> JOB ADDRESS: -7 �J('j�) PERMIT SR#: DD�nV5510 <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#: t-}C� Expiration Date: C <br /> Date: C>(a . 113 . C Contractor: 0 --Cr l <::,I <br /> Signature: Ti e: <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 /> _1 have and will maintain a certificate of consent to self-insure for workers' compensation, as provided for by <br /> /Section 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 the performance of the work for which this permit is issued. My workers' compensation insurance <br /> carrier and policy numbers are: <br /> Carrier: 0 Lc. . i— PG. ,kv� Policy Number: n6 <br /> _ I certify 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 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, I 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 /> ($100,000.), IN ADDITION TO THE COST OF/CPMPENSATION, INTEREST,ATTORNEY'S FEES,AND DAMAGES AS <br /> PROVIDED FOR IN SECTION 3706 OF TH L OR CODE. <br /> I, // (signature ofC-57 licensed authorized representative), <br /> hereby authorize (print name) 2(236P� L—L�P - Lei (` I I- R) <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 /> 5-17-2000 1 MI <br />