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77Z '`2ouJ <br /> San Joaquin County Environmental Health Services, Unit IV Well Permit Application Suppiameant <br /> J013ADDRESS:�S/-J !� iZoIC,1_, PERMIT SR#: 00 2-q <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> I hereby affirm that I am licensed under the provislons of Chapter g(commencing with Section 7000)of Divislon <br /> 3 of the Business and Professions Code and Ty license is in full force and effect. <br /> License#:CS 7 YJJ-Lj -- Expiration Date: / !�1 10 <br /> Date:_—(_ � �Contraclor: yrIYIoK <br /> signature; C�bYCOIJ 0&dtd Title;[�j ppl/lfpwoO[eJI <br /> Printed name; �X&a4il homwii <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the following declarations: (CHECK ALL THAT APPLY) <br /> Xhave 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 /> 'KI have and will maintain workers'compensation insurance,as required by Section 3700 of the Labor Code, <br /> forthe performance of the work for which this permit is Issued. My workers'compensation insurance <br /> carrier and policy numbers are: <br /> Carrier:G 30�'' ��_ PofieyNumber6%�Owzix riiinC= <br /> I certify that in the performance of the work for which this permit; 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 <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 /> Dale:-_ SE 11bL0� —Signature: , /ly�'sell�'yl/49- ' <br /> Printed Nome: <br /> WARNING: FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT <br /> AN EMPLOYERTO 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 /> I, IV <br /> _(Signature ofC-57 licensed authorized representative), <br /> hereby authorize(print name) \5 <br /> to sign this San Joaquin County Wall Permit Application on my hohalf. I 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 /> 517.20001 MI <br />