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Ch <br /> San Joaquin County Environmental Health Department Unit IV Well Permit Application Supplement <br /> � � lj <br /> JOB'ADDRESS: ° ' ' ' i-� Fn3_ PERCIAIT SR#:' <br /> r 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 Cade and my license is in full force and effect. <br /> _ License :' d o '� t - Expiration Date: <br /> Date: Contractor:- C <br /> �. I <br /> 'Signature: .. Title: z i <br /> 1 <br /> Printed name: : - <br /> .-,. A � <br /> WORKERS' COMPENSATION DECLARATION <br /> `I hereby"affirm under penalty of penury one of the following declarations:. (CHECK ALL THAT APPLY) <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 Code, for the performance of the work for which this permit is issued. <br /> 1/ i have and will maintain workers' compensation insurance, as required by Section 3700 of the Labor Code, i <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: 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 if I <br /> should become subject to the workers' compensation provisions of Section 3700 of the Labor Code, I shall <br /> forthwi <br /> t <br /> h comply with those provisions. <br /> 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 CIVIL FINES UP TO ONE,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 /> 1, ( (signature ofC-57 licensed authorized representative), <br /> `1 �'1 :�.�' ' �T• .r. "{"''°-.....�. �� � ,Y . � }'+ate.:�':' ��""e <br /> hereby authorize'(priht,name <br /> )' <br /> to sign this San Joaquin County Well Permit Application on my behalf. 1 understand this authorization is valid for. <br /> one(1)year and is limited to the work plan dated on the front page of this application. <br /> 1-25-02!MI t <br /> - 1i <br />