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San Joa in County Envjronme al Health Department Unit IV Well Permit Application Supplemental <br /> JOB ADDRESS: MIT 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 effect <br /> License# (23 (o 387 Exp Date 1/3 ) /2y f D <br /> Date 3109 Contractor Pge Gj 51 f>N SAM O i I o S j uL <br /> Signature Title L-2CA-T70n1 MA7uJA60K <br /> Pnnt Name GREIJLA f le 6JL1F0A-h <br /> WORKER'S COMPENSATION 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 by Section 3700 of the <br /> Labor Code for the performance of the work for which this permit Is Issued My workers' <br /> compensation Insurance carrier and policy numbers are <br /> 1rJTE4NpTIL►uHL- <br /> Carrier: ELI AL�_ Policy Number: �J4 3 L4 1 $ 1.1 (CP, <br /> MA-A-N+ OMiAtil <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 Code I shall forthwith comply with those proIslons <br /> Exp. Date:_ 7I1 ' 1-01O Signature: % �Y� <br /> Print Name: 6 K F)J NA CKAV�IFOA-b <br /> WARNING, FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT AN EMPLOYER TO <br /> CRIMINAL PENALTIES AND CIVIL FINES UP TO f/00.000,IN ADDITION TO THE COST OF COMPENSATION.INTEREST. <br /> ATTORNEY'S FEES,AND DAMAGES AS PROVIDED FOR IN SECTION 770E OF THE LABOR CODE <br /> - Ul IJP ZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> j�{ Y1n (Si list I C-57 ' s dputhorized representative), <br /> hereby authorize(print name) 1 r ri�.�C �I ON . It"' sr <br /> sign this San Joaquin county Well Permit Application on my behalf. I understand this authorization is valid <br /> for one year and is limited to the work plan dated on the front page of this application. <br /> 0129r02/MI <br />