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10/03/2003 FRI 14:00 FAX Z002 <br /> San,}oayuEn Gounty Environmental Health(�SgNlces,Urtiit•IN Well•Permit•Application$upplsrnerit <br /> 2- W 'u✓ .� PERMIT SKU �Z <br /> JOB AlDDRESS: 3!52-0 <br /> LICENSED CONTRACTORS DECLARATION (LCD) 1 <br /> hereby affirm that I am licensed under file 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#: f7d Al! —Expiration bate: <br /> 3 Date: ontractor: �C <br /> Title' -v — — <br /> Signature: <br /> Printed name- • <br /> �--� <br /> WORKERS' COMPF-NSATION DECt_ARAVON <br /> I hereby 3ffJTM Under penalty of perjury one of the following decaarations: (CHECK ALL THAT APPLY) <br /> I have and will maintain a certificate of consent 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 perrnit is issued. <br /> I have and will maintain workers' compensation insurance, as requiredby <br /> Section cmpensation insurance ode <br /> for the performance of the work for which this permit is issued. Myworkers' <br /> carrier and policy numbers are: -Q� <br /> Carrier: ` policy Number: <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 lOrws of California, and agrees that it I <br /> compensation provisions of Sq,gtion 3700 of the Labor Code, 1 shall <br /> should become subject to the workers' <br /> forthwith c rmp y with biose provisions, <br /> u . Q:3 ^ - <br /> Date Signature'_ <br /> Printed Name:' �• Z' <br /> WARNING;FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT <br /> AN EMPLOYER TO CRIMINAA1-PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THQUSAND DOLLARS <br /> IADDITION TO THE <br /> N 97 6 COST N6 LABOR CODE. <br /> INTEREST,ATTORNE <br /> PROVIDED OR Y'S FEES,RAID DAMAGES AS <br /> (C-37 licensed authorized representative), hereby <br /> authorize v <br /> to sign this San Joaquin County Well permit Applicatlon on my behalf. 1 understand this autlioriaation is valid for <br /> Lone qLyq3r and is limited to the work plan darted on the frons page of this ap liestion. _•_ –�—• <br /> No?NH INVPs'o l EEE i-70-3 1 <br />