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San Joaquin County Environmental Health Servicas, Unit 1V Well Permit Application Supplement <br />JOB ADDRESS: <br />PERMIT SR#: <br />LICENSED CONTRACTORS DECLARATION (LCD <br />I hereby affirm that 1 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 #: Expiration Date: <br />Date: j I a I O J - Contractor 4�' v avi(,e <br />1 <br />Signature: l/� L l� Title: 67eo 10 <br />Printed name: ?'; T, c,.n Z", <br />WORKERS' COMPENSATION DECLARATION <br />1 hereby affirm under penalty of pedury one of the following declarations: (CHECK ALL THAT APPLY) <br />I have and will maintain a certificate of consent to self -insure for workers' compensation, as provided for by <br />Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. <br />,-�(l 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: C` �l �' r J Policy Number: �) -7 q U <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, 1 shall <br />forthwith comply with those provisions. <br />Date: � I �" � �' •-' Signature: <br />Printed Name: b`Z v ;, , <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 />1, (C-57 licensed authorized representative), hereby <br />authorize <br />to sign this San Joaquin County Well Permit Application on my behalf. 1 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 />5-17-2000 / MI <br />