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San Joaquin County Envirc tntal Health Department Unit IV Well P t Application Supplement <br />JOB ADDRESS: 22/ kJ, w, PERMIT SR#: 9?3?7, <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 3 of the Business <br />and Professions Code and my license is in full force and effect. <br />License #: 5/22 6 S' <br />Date: <br /> <br />Expiration Date: 4/3i0/0S-- <br /> <br />Contractor: Sped-16'444 45ric01-4NArv / i' /01 - <br /> <br />Signature: <br /> <br />Title: <br /> <br />Printed name: k1/1 <br /> <br />WORKERS' COMPENSATION DECLARATION <br />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 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 of the Labor Code, <br />for the performance of the work for which this permit is issued. My workers' compensation insurance <br />carrier and policy numbers are: <br />Carrier: tiRfiell440 f c T1 - Policy Number: <br />I certify that in the performance of the work for which this permit is issued, Ishaff 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 />Signature: <br />Printed Name: <br />WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL SUBJECT AN EMPLOYER TO <br />CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS ($100,000.), IN ADDITION TO THE COST OF <br />COMPENSATION, INTEREST, 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 />I, Ji L14 a',.1,6kr (signature ofC-57 licensed authorized representative), <br />hereby authorize (print name) I in <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 />Date: 61210