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Q <br /> San Joaquin County Environmegtal Health Department Unit IV Well Permit Application Supplement <br /> Yoknv-!r AW . <br /> JOB ADDRESS: L,,,J PERMIT SR#: <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> I hereby affirm that I am licensed under the provisions of Chapter 9 (commencing with Section 70of Division <br /> 3 of the Business and/Professions Code and my license is in full force and effect. �1 <br /> License#: ( � 57��� Expiration Date: -10131109 <br /> 101 <br /> 3 Date: Co tract <br /> I <br /> Signature: 1 Title. <br /> Printed name: CL <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the following declarations: (CHECK ONE) <br /> i <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 /> p� <br /> � ave 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 /> Carrier. c(�r,J lel G/ Policy Number: 66 /0 ( ��� <br /> i 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 /> s should become subject to the workers' compensation provisions of Section 00 of the Labor Code, I shall <br /> forthwith comply with those provisions. <br /> Expiration Dat%&/< 6 Signature: 22LIf iv <br /> .Printed Name: <br /> WARNING: FAILURE TO SECURE WORKERS'COMPENSATION C VERAGE IS UNLAWFUL,AND SHALL SUBJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> ($700,000.),IN ADDITION TO THE COST OF COMPENSATION, INTEREST,ATTORNEY'S FEES,AND DAMAGES AS <br /> PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. <br /> AUTHOLRIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> I, (signature ofC-57 licensed authorized representative), <br /> hereby authorize(print namelS <br /> to sign this an Joaquin County Well Permit Application on my behalf. I unde tand this authorization is valid for <br /> one(1)year and is limited to the work plan dated on the front page of this application. <br /> 8-29-021 MI <br /> _ EHD 29-02-001 <br /> lJ)21n4 <br />