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San Joaquin County Environmental Health Department Unit IV Well Permit Application Supplemental <br /> JOB ADDRESS: 525 W WGA--' PERMIT SR # <br /> STcxk'-roN t� <br /> 'LICENSED CONTRACTORS DECLARATION (LCD) <br /> I hereby affirm that I am licensed under the provisions of Chapter 9 (commencing with Section 7000) of <br /> Division 3 of theBusinessand Professions Code and my license is in full force and effect. <br /> License#: ! ✓ I U Exp Date: I — �3 I I O 1 <br /> Date: �7 Contractor: Cas GuG�2 Z) h n <br /> III G1 I y1L <br /> Signature: /�7 Title: 0 <br /> Print Name: To ny JG�Al-,o� mA I I U <br /> WORKER'S 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 <br /> provided for by section 3700 of the labor Code, for the performance of the work for which this <br /> permit is issued. <br /> I have and will maintain workers'compensation insurance, as required by Section 3700 of the <br /> Labor Code, for the performance of the work for which this permit is issued. My workers' <br /> compensation insurance carrier and policy numbers are: <br /> Carrier:A I(1-5 V-1-- 0 X-it 0 m lPolicy Number: 0,6 E W SSC)5 3 1 <br /> 1 certify that in the performance of the work for which this permit is issued, I shall not employ any <br /> person in any manner so as to become subject to the workers' compensation law of California, and <br /> agree that if I should become subject to workers' compensation provisions of Section 3700 of the <br /> Labor Code, I shall forthwith comply with those provisions. <br /> Exp. Date: rJ ' I _ 0q Signature: 11 <br /> Print Name: TO V1 V O A 'rAK,4 I] <br /> WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT AN EMPLOYER TO <br /> CRIMINAL PENALTIES AND CIVIL FINES UP TO$100,000,IN ADDITION TO THE COST OF COMPENSATION,INTEREST, <br /> ATTORNEY'S FEES,AND DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. <br /> OR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> 7_9 <br /> (signature of C-57 licensed authorized representative), <br /> hereby authorize (print name) 'to <br /> sign this San Joaquin county Well Permit Application on my behalf. I understand this authorization is valid <br /> for one year and is limited to the work plan dated on the front page of this application. <br /> IV29/021MI <br /> WELL PERMIT APP <br /> EHD2&01 1115107 <br />