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U <br />� I <br /> San Joaquin County Environmental Health Department Unit IV Well Permit Application Supplement <br /> JOB ADDRESS: h5olg*, LJ 1'4>5aAnu_ ,t f�ERMIT SR#: <br /> j <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> I hereby affirm that I am licensed under the provisions of Chapter 9`(oommencing with Section 7000) of Division <br /> 3 of the Business and Profession's/Code and my license is in full force and effect. / �7 <br /> License#: �P SZv �!� Expiration Date//: <br /> Date: (J Contract r: (//C <br /> I Signature: <br /> 7r <br /> Printed name: <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 /> Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. <br /> 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 poli1cx�numbers are:i ��.Carrier: _ � )�Q��I� A — Policy Number: 6t!) <br /> l <br /> i <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 I <br /> I should become subject to the workers' compensation provisions of Section 3700 of the Labor Code, I shall <br /> forthwith comply with those provisions. <br /> i J p � <br /> Expiration Date: �// /D(1Signature: <br /> Printed Name: <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 /> ($100,000.), 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 /> AUTHORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> I, - (signature ofC-57 licensed authorized representative), <br /> K <br /> hereby authorize(p int name) oyz <br /> fto sign this San Joaquin County Well Permit Application on mybeh . I understand 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 /> 8-29-02/MI <br /> EHD 29-02-001 <br /> { 622/04 <br />