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San Joaquin County Environmental Health Department Unit IV Well Permit Appli satin Supplement <br />JOB ADDRESS: S11 3 o S � 'ie/9 L fft/Z GUz✓ PERMITS : <br />�2D %Q.y'y 64 95'377 <br />LICENSED CONTRACTORS DECLARATION (LCD)l <br />I hereby affirm than I am licensed under the provisions of Chapter a (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 #: 4L.4 <br />Date: f <br />Signature: <br />Printed name: <br />WORKERS'COMPENSATION DECLARATION <br />I hereby affirm under penalty of perjury one of the following declarations: (CHECK CINE) <br />_ I have and will maintain a certificate of consent to setf4risure for workers' rx1'ntpensation, as provided for <br />by 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 the Labor Code, <br />for the performance of the 'work for which this permit is issued. My workers' compensation insurance <br />carrier and `policy numbem are: �a f <br />Carrier. c,-.+ ! I Policy Number. <br />I certify that in the performance of the work for which this permit is issued, I shall not emplpy any person in <br />any manner so as to become subject to the workers' compensation laws of California, and agree that ff I <br />should become subject to the workers' compensation provisions of Section 3700 of the Labor Code, I shall <br />forthwith comply with those' provisions. <br />Expiration Date: l Signature: <br />O <br />Painted Natne: Pic <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 001A ARS <br />($100,000.), IN ADDITION TO TF* COST OF COMPENSATION, INTEREST, ATTORNEY'S FEES, AND DAMAGES AS <br />PROVIDED FOR IN SECTION 3706 OF THE LABOR COOT - <br />1T I FOR OTHER THAN C-67 SIGNING PERMIT APPLICATION <br />1, (signature ofC-57 licensed authorized mpr ntad"), <br />hereby authorize (pifnt name); <br />i <br />to sign this San Joaquin County Well Permit Appileadon on my behaff. 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 />3-2"2 / MI <br />15 RD 29-02-001 <br />624JiJ4 <br />