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1;9.1'/+'1 40\ 14718 FAX 1 916 -651 043U �c�un-an�n.y:��.•.� -- <br />FSon Joaquin County Environmental Health Smvicea, Unit IV Well Pamttt AppllCatlQD 15UpptemeM <br />JOB ADDRESS: 411-1 N WeSY t�L, I�r. , (1� PERMIT SRO: <br />LICENSED CONTRACTORS DECLARATION (LCD) <br />hereby affirm that I em licensed under the provisions of Chapter 9 (commencing With Section 7000) Of Division <br />3 of tha Bus'nsss5e^nd1^P7rofessiona Code and{ my Icense Is In fill force and affect. 1 <br />License # ._�.7 f i} S l O Expiration Date; _ l ` O <br />Date- -O C tractor: Cas(ct <br />Signature: TKI*: <br />Printed name: 4 C �%- �f , a D !CA <br />WORKERS' COMPENSATION DECLARATION <br />I haraty arfirm under penalty of perjury one of me following declarations: (CHECK ALL THAT APPLY) <br />_ I have end will maintain a Certificate of consent to self -insure for workwV compvnaation, as provided for by <br />Section 3700 of the Leoor Code, for the performance of the work for which this permlt Is issued. <br />I I have and vA'I maintain workers' compensation insurance, as required Uy Section 37W of the Labor Code. <br />for the performance of the work for which this permit }s issued. My workers' Compensation Insurance <br />ca-rie, and policy numbers are: <br />"j Carrier: CLS KQ-a'nlit% Policy Number. <br />JI _ I certify that In fie parformunce of the worts for whkr+ this permit fs issued, I shill not employ any person in <br />any manner so an to become subject to the wa*0-5' cOrr1Pen58tiOn laws of Callfomia, and a0roe that if I <br />shm!d become sub)ect to the wCOers' compensatlon pro of Sect 3700 of the Labor Code, I snail <br />fodpjwYth comply with mase provislo:is. <br />4 Data: 1— 1 —O Slgnature: _' - <br />Printed Name:`y pry a <br />WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGI! Is UNLAWFUL, AND SMALL SUBJECT <br />` AN EMPLOYER TO CRIMINAL f ENALTIEa ANo CML FINES UP TO 011E HUNDRED THOUSAND DOLLARS <br />! ($100,000.1, IN ADDITION TO THE CAST OF COMPENSATION, INTEREST, ATTORNEYS FEES, AND DAMAGES AS <br />PR0VMFD FOR IN SECTION 3706 OF THE LABOR CODE. <br />(sign -tum ofG-V licsnaad autftorfzad rspressntative), <br />! harvoy autf►o►iza (print narM) 1` Qi IeA I L vim• - — <br />to sifln this San Joaquin County WW Parmlt AppliCetlon on my behalf. r understand alis authorization Is valid for <br />one (1) year ane is Iimlted to the mora plan d&Wd on the front page o1 this MWICStbn- <br />6.17 <br />f� f TE:£T east/9alZ1 <br />G <br />V6 39v<d aCiO� H1�I EEvE89ti60� <br />W <br />