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San Joaquin County Environmental Health Department Unit IV Well Permit Application Supplemental <br /> JOB ADDRESS: 3 &f� d,-R- PERMIT SR# 05533 <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#: 71 7 Sl D Exp Date: 1 . 3 1 . 10 IAz <br /> Date: . 2(o. O Contractor: C�rsQhbG L 1 -I N L-2 1N c.. <br /> Signature: \ Title: <br /> Print Name: <XA-� M`'-L <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 /> VII 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 /> Carrier: &A-gltA- 0A-n0n0A-L- Policy Number: OK EW S 30531 _ <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' co ensation pr ns of Section 3700 of the <br /> Labar�Code, I shall forthwith comply with those pr isins. <br /> Exp. Date: ( • O Signature: - <br /> Print Name: Vip <br /> WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT AN EMPLOYER TO <br /> CRIMINAL PENALTIES AND CIVIL FINES UP TO$100,000,IN ADDITION TO THE COST OF COMPENSATION,INTEREST, <br /> ATTORNEY'S FEES,AND DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. <br /> AU ORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> 1, ' (signature of C-57 licensed authorized representative), <br /> hereby authorize(print name) 1&.7Y . ,to <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 /> R/29/02/MI <br /> EHD 29-01 11/5/07 <br /> WELL PERMIT APP <br />