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San Joaquin County Environmental Health Department Unit IV Well Permit Application Supplamern <br /> JOB ADDRESS: PERMIT SRp: <br /> LICENSED CONTRACTORS DECLARATION (LCQ) <br /> I hereby affirm that I am licensed underthe provisions of Chapter a(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 p: <br /> Expiration Date: <br /> Date: Contractor. <br /> Signature: Title: <br /> Printed name: <br /> WORKERS'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-Insum for workers'compensation,as provided for <br /> by Section 3700 of the Labor Code,for the performance of the work forwhich 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 workers'compensation insurance <br /> tamer and policy numbers are: <br /> Carrier: 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 ff 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 /> Explmfion Date: Signature: <br /> Printed Name: <br /> WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CML FINES Up TOONE HUNDRED THOUSAND DOLLARS <br /> ($100,000.),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 /> AUTHORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> ) <br /> --�---�--/ J /// (sgnatun o/C-a7lkansatl aWhorhed rapreaenWive), <br /> ne <br /> hereby authorize(print me)&t 5lTii it <br /> y <br /> to sign this San Joaquin County Well Penna ApPgpeOon on my behalf. I understand this authorization Is valid for <br />