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06/14/2004 09:07 2094683433 FIFTH FLOOR, rant ej <br /> San Joaquin County Environmental <br /> E/.n�,vironmental Health Department Unit IV Well Permit Application Supplement <br /> JOB ADDRESS: (O i "` PERMIT SR#: <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> I hereby affirm that 1 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* oQ l�lJ� Expiration Date: <br /> Date. , I Contractor: <br /> Signature: aM <br /> Printed name: <br /> WORKER ' 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 provided for <br /> by Section 3700 of the Labor Code, for the performance of the work for which this permit is Issued. <br /> 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 /> Carrie )1 /� 1 S Policy Numher: <br /> t o 10C1L� <br /> Carrier. 6t &1 <br /> 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 /> Expiration Date: 6 5i9nature: <br /> Printed Name: / <br /> WARNING:FAILURE TO SECURE WORKERS'COMPENSAfIUN COVER GE IS UNLAWi=UL,AND SHALL SUEJEOT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL PINES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> IN ADDITION TO THE COST OF COMPENSATION,INTEREST,ATTORNEY'S FEES,AND DAMAGES AS <br /> PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE- <br /> AU7HRIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> I (signature afC-57 licensed authorized representative), <br /> hereby authorize(print na ) M Z� c <br /> to sign this San Joaquin County Well Perrnit Applicatlon on my behalf. I understand this authorization Is valid for <br /> one(1)year and 18 limited to the work plan dated on the front page of this application. <br /> 8-29-02 1 MI <br /> END 2%4)2.001 <br /> 9/30/2003 <br /> of map i epi RjeW -- et E : 1 I fs0 81 noN <br />