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,02/13/2001 08:36 2094602433 <br /> <br />FIFTH FLOOR PAGE 03 <br />San Joaquin County Environmental Health Services, Unit IV Well Permit Application Supplement <br />JOB ADDRESS: Le4rat.i-i'ytt,c, P-Geh,',7E 2ERMiT SR#: <br /> <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 the Business and Professions Code and my license is in full force and effect. <br />License #: (-1)67-0 407 Expiration Date: /CV.3 / I °-z--- <br /> <br />Date: 7 /61 /0 / Contrac r y _s <br />Signature: ALLy2i Title: / Key <br />Printed name: /4-7-2-(1 ( <br /> 9(t-- <br />WORKERS' COMPENSATION DECLARATION <br />I hereby affirm under penalty of perjury one of the following declarations: (CHECK ALL THAT APPLY) <br />I nave 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 />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 /> <br />Carrier: /1 /a, 0.1('/4kei Policy Number: & )(1-- 5-0 S-6-' <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, I shall <br />forthwith comply with those provisions. <br />Date: Signature: <br />Printed Name: 0/ ?a- r a-1 Wec. ( a -0 <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 /> (C-57 licensed authorized representative), hereby <br />€-4 'th -Pe T`-m -)-/ (Y/7/0 /2 7 /4,J/ <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 />5-17-2000 MI <br />_ IL <br />authorize <br />54,n) a33