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San Joaquin Coynty Environmental Health Services, Unit IV Well Permit Application Supplarnont <br /> ti <br /> JOB ADDRESS:�SZ✓ !�o/���o��� jQty��PERMIT SR$: <br /> LICENSED CONTRACTORS DECLARATION (LCQ) <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 force and effect. <br /> i <br /> License#:Gf 7 ` 9176.E - Expiration Date: l I n/ 10�f <br /> Date:_`j� Owe__ -,._Contraclar. an, t, <br /> Signature: I^ Title: 676kx/ &&q, <br /> 7 <br /> Printed name: j ty pmflo/' <br /> WORKERS' COMPENSATION DECLARATION <br /> I hr-reby affirm under penalty of perjury one of the following declarations: (CHECK ALL THAT APPLY) <br /> Xhave and will maint on a certificate of cauenl 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 /> 16 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: Y-1— aft_, Policy Number, <br /> I certify that in the performance of the work for which this permit I 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 31 <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 /> Date: Q2 _Signature: <br /> Printed Nome: /r1f0�7�Y' �uA E'r <br /> WARNING: FAILURE To SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT <br /> AN EMPLOYFR70 CRIMINAL PENALTIES AND CIVIL FINES UPTO 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 1706 of THE LABOR CODE <br /> (� (ssiig(nattu�reeofCC•5T licensed authorized representative), <br /> hereby authorize Iprinl name) as) <br /> 1D sign this San Joaquin County Wall Permit Application on my behalf. 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 /> SIT-20001 MI <br />