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PTs t9 <br /> San Joaquin Cou Environ Health Departrwrit Unit 11Y Well Permit Application Supplement <br /> 1! Uf ��`` SIto518�3 <br /> JOB ADDRESS:-5d w• b PERMIT SR#.� 051 94-q <br /> 7 _ <br /> — 9b 6Y'` o51B� 6 <br /> slg�� <br /> LICENSED CONTRACTORS DECLARATIONL( CD) <br /> I hereby affirm that I 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#: Lt C` 7 // Expiration Date: <br /> Date: 01 �i 7 Contractor <br /> Signature: <br /> Printed name: 0aF - <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 cerMicate 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 /> 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 /> carrier and policy numbers are: <br /> Carrier: L L1 oi, L 11 G l T Policy Number. <br /> I certify that in the performance of the work for which this perm is issued, I shall not employ any person in <br /> any manner so as to become subject to the workers'compensation taws of California,and agree that if I <br /> should become subject to the workers'compensabon provisions of Section 3700 of the labor Code, I shall <br /> forthwith comply with those provisions. <br /> Expiration Date: I I C' Signature: LC='1C=�� <br /> Printed Name: <br /> WARMW:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CML FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> (:100.000.1 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 APPUCATION <br /> (signature ofC-67 licensed authorized representative), <br /> r <br /> hereby autlwrtie(print name) `-t'% " <br /> to sign this San Joaquin County Well Permit Application on my If. I undomtand this authorization Is valid for <br /> one(1)year and Is limited to the worts pian dated on the front page of this application. <br /> 8-29.021 MI <br /> EHD 29.02-001 <br /> 6.22/04 <br />