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aesE 3 0� i r* S <br />San Joaquin County Environmental Health Department Unit IV well Permit Application /Supplement <br />JOB ADDRESS: ZZ(`� N . ill( PERMIT SFS#: DDY � 5,9 O <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 tho Business and Professions Code and my littnse is in full force and effect. <br />License: — f 1 5 Expiration Date: I c <br />Date: �o f , + U Cont c r: —Lf e�— G �% ` (YL�/l r G <br />Signature; Title <br />J <br />Printed name: <br />WORKERS' COMPENSATION DECLARATION <br />I hereby affirm under penalty of perJury one of the following declarations: (CHECK ONE) <br />1 have and will maintain a certificate of consent to self4risure for workers' compensation, as provided for <br />by Section 3700 of the Labor Code, for the porformance 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 tabor Code, <br />for the performance of the work for whlch this permit is issued. My workers' compensation insurance <br />carrier and policy numbers aro: r <br />Carrier: ffi h �l� K I `�_ +( d� &` Policy Number. o (�.. S 3 a 133 l <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 se 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 37 of the Labor Code, I shall <br />forthwith comply wlth those provlslons. <br />Expiration Date: "J � � J � /Sigjrkature: <br />Printed Name <br />WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE I$ UNLAWFUL, AND SHALL SUBJl;CT <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, ATTORNE'Y'S FEES, AND 0AMA(;ES AS <br />PROVIDER FOR IN SECTION 3706 OF THE LABOR CODE. <br />hereby nuthvrize (print <br />TION ?O�R QriHER THAN C-57 SIGNING PERMIT APPLICATION <br />nature afG-57 licensed authorized representative), <br />:�, L -L- L_ 11 -rue <br />6 - <br />to <br />to sign this Sin Joaquin County Well Permit Application an my behalf. I understand this authorization is valid for <br />one (1) year and is limited to tho work pi®n dsted on the front page of thie application. <br />MI <br />EHp 29.02-001 <br />