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s y <br /> Sen Joaquiin County Environmental Health$ervkee, Unit IV Well Permit Application Supplement i <br /> I JOB ADDRESS 1,5 CA N/AiPlcn BLS.-�J�AC` PERMIT SRO: <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> I hereny affirm that 1001 licensed under the WOVISlen9Of ChaPM'9(Wrnmencing with Section 7000)of Division <br /> +3 of the Business and Pmlwwians Code and my license is in full force and effect i <br /> U I <br /> License#: ,- -- —� 1� E irafion Date: Lo 1 _ . <br /> Date <br /> Signature: Title: _ I <br /> l Printed narne: <br /> WORKERS'COMPENSATION DECLARATION <br /> I hereby affirm under penalty of peoury one of the following deciarstion& (CHECK ALL THAT APPLY) <br /> i <br /> _1 hays and will maintain a certificate of consent lo 9eif-insure for workers'ovmpensation,as provided fox by <br /> Section 3700 of the Lalaor Code,for the perforrnama of the work for which this permit is Issued. <br /> ' I have and wKI maintain wA*rkera' t:Cfrnporl9210A lnlluranca, ai required by Saebors 3700 of the Labor Code <br /> for the psrformanoe of the Work for which this permit is issued. My workera'compensation insurm,ce <br /> carrier and policy nurnbera We: <br /> Ca^t4r= Policy Number• <br /> I certify that in the performance of the work fOr which this perm$is issued, I shall not employ any person 1h <br /> any manner so as to become subject to the workers'compensation law& of Celifprnla, and agree that if I <br /> should berome subject 10 the workers'campgrjt,on Provisions of Section 3744 of the Labor Code, !,shall <br /> f0thwith comply with those provisos$. <br /> I <br /> vete: ♦ I `Signature; xz <br /> i <br /> f Printed Name: <br /> WARNING:FAILURE TD SEGtJRE <br /> WORKERS,COMPEN"TION COVERAGE Ig UNLAWFUL,AND SHALL SUi3JECT <br /> All,EllnrLoyER To CRINNAL PENALTIES AND CIVIL FlNas UP TO ONE FItlNORED THOusAND DOLLARS <br /> ` ($100,080.),IN ADDITION TO THE LOST OF COMPENSATION,INTER93T.ArMRNEY'S FEES,AND DAMAGE$ A: <br /> PROVIDED FOR IN SECTION 3706 OF TPI!'LABOR COQ <br /> 1, 3 <br /> aurhnn;� (Ci7 Ilcaltsed authorized re <br /> Pf88lrit#tlypy, nOrAby l <br /> to ajar,this$an J � <br /> osgtrin County NWI Parrhit Application on <br /> llrMy behalf. f understa this# <br /> `°rtg ear and Is 111td tD tt*work <br /> Irlri Ceteq or, utharization iy vy};a far <br /> �fro_rtt�j Q of thio aonlr <br /> WQLf� 1^ld 10 f 6861-=Qt-�+! <br />