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Apr 28 05 11 : 30a q <br /> P• <br /> San Joaquin County Environmental Health�Department Unit IV Well Permit Application Supplement <br /> JOB ADDRESS:3r7,00 t ZT(/ yxl ilt)Y PERMIT SR#: <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> I hereby affirm that I am licensed under the provisions of Chapter 9(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#`:IGS 7 V(F•T1(� Expiration Date: <br /> T <br /> Date: Z Contr <br /> Signature: Title: <br /> r- <br /> Printed name: l <br /> i <br /> WORKERS' COMPENSATION DECLARATION <br /> 1 hereby affirm under penalty of perjury one of the following declarations: (CHECK ONE) <br /> haveand will maintain a certificate of consent to self-insure for workers'compensation, as provided for <br /> a <br /> y Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. <br /> _I hve 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 policynhytubers re: <br /> Carrier: �l' Policy Number: <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 /> 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:S4 f=Aignature: tyles_ <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 /> AUTH I TIO J,F )R OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> h IK j/~/ — (signature ofCS7 licensed authorized representative), <br /> hereby authorize(print name) <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 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 /> 6/22/04 <br />