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San Joaquin Cou/n/ty En�viironmental Health Department Unit IV Well Permit Application Supplemental <br /> 6l <br /> JOB ADDRESS: / • i �x'��` - /-05E I B' <br /> PERMIT SR#�. D SY/5 y <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 /> c c <br /> License#: l Exp Date:? � <br /> Date: Contractor:-7_3s'',� �x k t` <br /> r _ <br /> Signature°" = _ Title: ; <br /> Print Name: " T. <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 Cade, for the performance of the work for which this <br /> permit is issued. <br /> I 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; rz�e ��4� r Policy Number: <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' compensation provisions of Section 3700 of the <br /> Labor Code_. I shall forthwith comply with those provisions. <br /> Exp. Date: 7 Signature: <br /> 0A4_;e_1t1 bj �. 6;� Print Name: <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 /> ATTORNEYS FEES,AND DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. <br /> AUTHORIZATION FOR OT AER THAN C-57 SIGNING PERMIT APPLICATION <br /> signature of C-57 licensed authorized representative), <br /> hereby authorize(print ame){ �,ti ��`; �i ,��c �, r r= r� c�i ,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 /> R129(!1?/MI <br /> END 29-01 1115107 <br /> WELL PER611?F PP <br />