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San Joaquin County Environmental Health Department Unit IV Well Permit Application Supplemental <br /> JOB ADDRESS: _5 US but/tv l 0A_ PFRMIT SR # <br /> V) al ------- <br /> 1 <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> 1 hereby affirm that I am licensed under the provisions of Chapter 9 (commencing with Section 7000) of <br /> Division 3 of the Business and Professions Code and my license is in full force and effect. <br /> License#: '1�9."07-(v __Exp Date: _ _ <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> -{ <br /> 1C. ,)2LnCc- <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 subject to the workers'compensation law of California. and <br /> agree that it 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: I Z p l I _ Signature: <br /> Print Name: <br /> WARNING:FAILURE YO 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 /> i <br /> i <br /> AUTHORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> 1• C-1_k is J-A'-T L) _ (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 /> R1291071MI <br />