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)I-Af� <br /> 16 <br /> San Joaquin County Environmental Health Department Unit IV,Well Permit Application Supplement <br /> JOB ADDRESS: /Z,5-0 /I- Wl1-Su►l W -Cr-0e14 RMI11 SR#:� <br /> I l <br /> LICENSED CONTRACTORS DECLARATION (LCDj <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 Code and my license is in full force`and effect. <br /> License#: $/ `� i <br />� Expiration Date: �1~ <br /> _ n li <br /> Date: b/- a3- cs� Contractor�ai �� 874c,� ��1LLt.t6 �,,n�14 Wiwi/��z�^� l�ruCL <br /> Signature-- Title: l <br /> Printed name d-_,r,4hi'4 <br /> r <br /> WORKERS' 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 consent 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 /> If ✓ I 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 /> L ,V __ Policy Number:I, � <br /> Carrier: / �4� t t al+-:d � r: Z,2 W 6V A' "-'713 1 <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 <br /> should become subject to the workers' compensation provisions of Section 3700 of the ac cede; I shall <br /> forthwith comply with those provisions. p •, <br /> Expiration Date: a y-61- a J Signature z 6", <br /> Printed Named cele <br /> i} <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 /> QQQ. IN ADDITION TO THE <br /> COST OF COMPENSATION,INTEREST ATTORNEY'S FEES AND DAMAGES AS <br /> ($1QQ, }� � t � <br /> PROVIDED FOR IN SECTION 3708 OF THE LABOR CODE. l <br /> AUTHORIZATION AOR THAN C-57 SIGNING PERMIT APPLICATION <br /> I, (si nature ofC-57 licensed authorized representative), t <br /> r <br /> hereby authorize(print na e} r c+{it r 166L- <br /> to <br /> SLto sign this San Joaquin County Well Permit Application on my behalf. I;understand this authorization is valid for I <br /> one(7)year and is limited to the work plan dated on the front page of this application. <br /> 8-29-021 MI <br /> ISI } <br /> iR <br /> EHD 29-02-001 <br /> 6/12144 I'r <br /> L it <br />