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:F San Joaquin County Environmental Health Department Unit IV Well Permit Application Supplemental <br /> JOB ADDRESS: <br /> PERMIT SR # <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> :iereby affirm that I am licensed under the provisions of Chapter 9 (commencing with Section 70001 o',- <br /> Division <br /> `division 3 of the Business and Professions Code and rly license is in full force and effect. <br /> i License#. (o <br /> — -- — Exp Date: <br /> )ate: O(p�0 Contractor I t; <br /> Signature: J _�^ '`— tie:gl�ek O �CAJ <br /> i £'pint Name: <br /> i <br /> WORKER'S COMPENSATION DECLARATION <br /> i <br /> I 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 <br /> provided for by section 3700 of the labor Code, for the performance of the work for which this <br /> permit is issued I <br /> I <br /> I have and will maintain workers' compensation insurance, as required by Section 3700 of th <br /> for the performance of the work for which this permit is issued. My workers' <br /> compensation insurance carder and policy numbers are. <br /> Carrier:Z)(1 Gln AYt -iic u-, Policy Number: <br /> a V2c�1)(-"�L nCe- <br /> I certify that in the performance of the work for which this permit is issued, i shall not employ any <br /> person in any manner so as to become subtect to the workers'compensation law of California, and <br /> agree that if I should become Subject to workers' compensation provisions of Section 3700 of the <br /> Labor Code, I shall forthwith comply with those provisions. <br /> Exp. Date:_ Z0 l I Signature: / —=-/ -- <br /> Print Name: f—(S -y-A-TU <br /> U <br /> WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT AN EMPLOYER To <br /> CRIMINAL PENALTIES AND CIViL FINES UP TO$100,000.IN ADDITION TO THE COST OF COMPENSATION,INTEREST. <br /> ATTORNEY'S FEES,AND DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. <br /> AUTHORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> L-1-t Z t S TPCF U 1✓1 (signature of C-57 licensed authorized representative), <br /> hereby authorize(print name) _ — to <br /> sign this San Joaquin county Well Permit Application on my behalf. I understand this authorization is valid <br /> for one year and is limited to the work pian dated on the front page of this application. <br /> wzgmzrMl <br /> [:+025-01 'LISA; <br /> VYFI.t.PERMIT 4PF' <br />