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San Joaquin County Environmental Health Department Unit IV Well Permit Application—Supplement <br /> JOB ADDRESS: 0E O 1 3_E-Q "L/V -_F1i5-7Q PERMIT SR#: <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> 1 hereby affirm that I am licensed under the provisions of Chapter 9 (commencing with Section 7000) of Division <br /> 3 of the Businessand Professions Cff ode and my license is in full force and eff ct. / <br /> License#:C';-7 `f'?�f 1`� Expiration Date: <br /> Date: ' Contra r. 1��' ��r( ��1 <br /> Signature: Title: 60 3'LticyNS <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <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 vi ions of Sec ion 3700 of the Labor Code, I shall <br /> forthwith complylyr ith those provisions. <br /> Expiration Date: 6 j C t Signature: 6W/ I(� I , /n <br /> Printed Name: C Si-c�Ne.ir Oyo_V)e_l� <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 /> AUT IZA N FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> I, (signature ofC-67 licensed authorized representative), <br /> —�--- <br /> IV <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 /> 8-29-021 MI <br /> EHD 29-02-001 <br /> 6/22/04 <br />