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San Joaquin County Environmental He81th Department Unit IV.Well Permit Application Supplement <br /> JOB ADDRESS: Z'�$�G PERMIT SR#:_5S _ <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> 1 hereby affirm that I am licensed under the provisions of Chapter 9(commencing with Section 7000):of Divlsiorr <br /> 3 of the Businesss and Professions Code and my license is in full force`and effect. <br /> License#: f �f'� Expiration Datei: <br /> Date: - C v u_ l�1 <br /> Foaq <br /> Signature: 717� Title: ilkS y' `ctvl� <br /> V <br /> Printed name: <br /> WORKERS'COMPEN$ATION•D)ECLARATION <br /> I hereby affirm under penalty of perjury one of the following declarations: (CHECKONE) <br /> _I have and will.maintain a certificate of consent to self4nsure for workers'compensation, as provided for <br /> fby 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 workerscompensation insurance <br /> carrier and policy numbers are: <br /> Carrier: � L� Policy Number: <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 /> 64Expiration Date: ( 0 Signature: <br /> Printed Name: r�s � +tom V)Gy-- <br /> W.ARNING: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 /> ($700,000.),IN APDITIONhTO THE COST OF COMPENSATION,INTEREST,ATTORNEY'S FEES,AND DAMAGES AS <br /> PROVIDED FOR IN SECTION 3706.OF THE LABOR CODE. <br /> TH T#O R OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> I, (signature ofC-57 licensed authorized representative), <br /> hereby authorize(print name) ' <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 /> 8-29.02/Ml <br /> EHD 29-02-001 <br /> 6/22/04 <br />