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R002/002 <br /> 05/09/2005 MON 15:08 FAX . 002 <br /> 05/09/2005 12:22 FAX 209 94808 - _ -••-w^—�--- <br /> San Joaquin County Environmental Health Department Unit IV Well Permit Ai <br /> p Supplement <br /> JOB ADDRESS: <br /> PERMIT SR#.LICENSED CONTRACTORS DECLARATION <br /> I hereby affirm that I am licensed under the provlsions of Chapter 9 (commencing with Section 70oo)of Division <br /> 3 of the Business and Professions Code and my license is in full force and effect. <br /> License Expiration Date: <br /> Date: C ntractor. <br /> Title: <br /> Signature: <br /> Printed name: lie <br /> WORKF-RS' COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the following declarations: (CHECK ONE) <br /> _I have and will maintain a certificate of cons <br /> 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 /> for the p rfo IrmancetOf the work forowhlch this Permit r snissued r My workerseode, <br /> compensation Insurance <br /> carrier and policy numbers are: <br /> Policy Number: <br /> Carrier: <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 /> forthwith comply with those pravlslons. <br /> Expiration Date: Signature: <br /> Printed Name: <br /> WARNING: <br /> NEMIN OYER TO TO SECURE NAL PENALTIESWRKS AND OMPIVIL FINES UP TO aNSATION COVE N:HUNDRED THOUSAND DOLLI�iti IS UNLAWFUL,AND ARS <br /> AN <br /> P <br /> $ROV DEo FaA N SECTION THO O THE COMPEN <br /> CSATION, INTEREST,ATTORNEY'S FEES,AND DAMAGES AS <br /> AUTHORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> (signature Qfc.17 licensed authorized representative), <br /> hereby authorize (print name) <br /> to sign this San Joaquin County Welt Permit Application on my behaif. t understand this authorization is valitl for <br /> one(1)year and Is limited to the work plan <br /> dated on the front page of this application. <br /> 9-29-021 MI <br /> 6HD 2`w2-0lll 05/09/2005 MON 11:06 CTX/RX NO 54201 2002 <br /> 05/09/2005 MON 16:23 [TX/RX NO 56031 [x002 <br />