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f< <br /> �rAY C;0-> C',6-/3 <br /> San again County Environmental Hemalth I]epa ent Unit 1V Wall Peftnk Applica bon Su <br /> pplemenf <br /> JOB AD RESS• is0o 5 W PERMIT SR#- <br /> LICENSED CONTRACTORS DECLARATIONL[ CD1 <br /> I hereby affirm that I am licensed under the provisions of Chapter 8(commencing with Section 7000)of Division � <br /> 3 of the Business and Professions Code and my license is in full to"and effect. <br /> License#: C`S 7 '7 I )15!510 <br /> / J/ <br /> Expiration Gate: ;/31 1+a <br /> Date: Contractor: l 5 <br /> Signature r~ Two, C. PSII <br /> Printed name- <br /> WORKERS'COMPENSATION DECLARATION <br /> I here affirm under <br /> by penalty of perjury one of the following declarations: (CHECK ONE) � <br /> i <br /> I have and will maintain a Certificate Of consent to seif-insure for workers,compensabon,as provided for <br /> by Section 3700 of the Labor Code,for the performance of the work for which this permit is issued. <br /> f—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 amid policy numbers are:NQS QS O Policy Number. 3 <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 sut>jed to the workers'compensation Provisions Of Section 3700 of the Labor Cods, I shall <br /> fodhwith comply with those provisions. <br /> Expiration Data: S-1-O 5_ _Signature: <br /> Printed Name: <br /> WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND Cf nL.FINES UP TO ONE HUNDRED THOUSAND DOU ARS <br /> (;f00,M-L IN ADDITION TO THE COST OF COMPENSATK)N,INTEREST,ATTORNE"FEES,AND DAMAGES AS <br /> PROVIDED FOR IN sECTm 3708 of THE LABOR CODE. <br /> AUTH IZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> I, algrrallue otC457 licensed authartzed representative), <br /> "' ' I <br /> hereby authorize(print name! -kl ►f�� .1._�l' �UC.t�l�,(/�-eZ U e4 <br /> to sign this San Joaquin County Well Permit Appticatron on my behaff. 1 understand this authorization is valid for <br /> one(11 year and is Ihnited to the work plan dated on the front page of this application. <br /> 8-28-021 MI <br /> PHD 24-02-001 <br /> 622104 <br />