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t - Application Supplement <br /> San Joaquin Countyi:nviranrnental Health 9ervlaes,unit IV Well Nertnit App ppment <br /> JOB ADDRESS-_____T 1. c1pa �._.� PERMIT SRW: ' <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> t hereby affirm that I am licensed under the provisions of Chapter 9 (commencing with Section 7000)of DivEalon <br /> 3 of the Business,snd Professions Code and my iicenso Is in full force and bffoot• <br /> X" `! -? <br /> License#:��! Explraticn Date: e!- J-+a ! .....� - <br /> ii / <br /> pate: - G-m 1 Contractor: l✓c 5i /Yrl rfi7 c�1t1 cC �c Lao...+° <br /> Slgnaturo: , e�f 4. • ✓►� Title: -J Lea ' <br /> Printet#name: <br /> a WORKERS' COMPENSATION DECLARATION <br /> 1 hereby affirm under penalty of perjury one of the following-declaratione: (CHECK AI_t_.THAT APPLY) J <br /> I have and will maintain a certificate of Consent to self-insure for workers'compensation.as provided for by � <br /> Section 3700 of the Labor Cudm, tai the performance of the work for which this permit is issued. J <br /> ✓ I have and will maintain workers'compensation insuranco,as required by .octl4n 3700 of the Labor Code, <br /> ft.o the f►eif'ormance of the work for which this permit is issued. My workari;'compensation insurance <br /> y <br /> "carder and policy numbers are: � <br /> Carrier✓ I ✓ 'K ;_Policy Number: ✓ Br w8 BI�KSz oa <br /> I rgrtlfy that in the performance of the work for whlen this permit is issued, 1511011 not employ any person in <br /> any manner so as to become subjectjo the workers'compensation IaWS of California, and agree that if I <br /> should become subject to the workers' compensation provisions of Section 3700 a thtiLmlagr Code, 1 shall <br /> forthwith comply with those provisions. <br /> Data, 61.16-6 / Signature: <br /> Printed Namv�f ,�-iz o <br /> WARNING:FAILURE SO SECURE WORKERS'COMPENWION COVERAGE IS UN -AWFUL,AND SHAL. SUBJECT <br /> AN EMPLOYER Yd CRIMINAL PENALTIES AND CIVIL.FINES UP TO ONE HUNDRED THOUSAND DOLLARS � <br /> (5100,000.),IN ADDITION TO P 970 OF THE LABOR CODTION,INTEREST,ATTORNEY'S FIFES,AND DAMAGES AS <br /> PROVIDED OR N 8EC CIOIJ <br /> I, <br /> licensed authorized evilmsontstive).humby <br /> i egjthorixe /LL i L.L__ bir D✓�„�C�f10 �+4 <br /> to sign this San Joaquin County Well Permit Application an my behalf. I understand thla authorization In valid tar <br /> ohe(1)year and Is limited to the work plan dated an the front page of this application. <br /> 6,17.20001 MI _. .� <br />