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2,7F FP:M:ENPREIB 15:05BSEE3P '-'1911,772f=.78 P <br />,34c', 27 3 <br />ti7746. <br />dc5nt <br />San Joaquin County Environmental Health Department Unit IV Well Permit Application Supplement <br />JOB ADDRESS: ?PiPihirvr PERMIT SR*: 6efit -5 7 ? <br />LICENSED CONTRACTORS DECLARATION (LCD) <br />I hereby affirm that I am licensed under the provisions of Chapter 9 (commencing with Section 7000) of 1:Yrvision <br />3 of the Business and Professions Code and my license is in full force and effect. <br />License #: ?-°? Expiration Date: 0 ({ I3D /1 00 V <br /> <br />Date: • ( 6-4›.) Contractor (Lk; p 0 <br />Signature: ( Title: CD‘Ad &/c.'" <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 fcr <br />by Se Ion 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 Coda, <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: Siti 1I C.tekp INC Policy Number: <br />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 />should become subject to the workers' compensation Provisions of Section 3700 of the Labor Code, I shall <br />"...° -F <br />forthwith comply with those provisions. <br />Expiration Date: / /0 Signature: <br /> <br /> <br />Printed Name: i4Asj ,s rt <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 ADDMON TO THE COST OF COMPENSATION, INTEREST, ATTORNEY'S FEES, AND DAMAGES AS <br />PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. <br />AUTE717N FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> (signature o(C-57 licensed authorized representative), <br />hereby authorize (print name) L.- c <br /> <br />to sign this San Joaquin County Well Permit Application on my behalf. I understand this authorization is valid for <br />one (1)year and isIhnitad to the work plan dated on the front page of this application. <br />8-29-02 / MI <br />F.IlD :9-02-001 <br />612iN