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I 44i:oo FAX A <br />, <br />San Joaquin- CoUnty Environmental <br />Health Servico,s, Unit.IV WeliPermit. Application Siipplernent <br />JOB ADDRESS: 2--(°(02.— 1.-) A.a...Q.ketN. _ • . 0.ERivwf skg DI:1:5_2_41._ <br />LICENSED CONTRACTORS DECLARATION (LCD) <br />I <br />hereby affirm that I am licensed under the provisions of Chapter 9 (commencing with Section 7000) <br />of Divison <br />3 of the Business and <br />Professions Code and my license is in full force and e(fect. <br />License #: 'M*10 Expiration bate: i • <br />Date: _., 0 II I) 2) ontraotor: • _/')C • <br />S <br /> Title <br /> <br />ignature: 4S. 0 .1 0 2 -4," <br />Printed name: <br />WORKERS' COMPENSATION DECLARATION <br />I hereby affirm under penalty of perjury one of the following declarations: <br />(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 'ict the Labor Code, for the performance of the work for which this permit is issued. <br />V' I have <br />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: F.AIYI Policy Number: <br />I <br />certify that in the perfOrmance of the work for with 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 it I <br />should become subject to the workers' compensation provisions of Setcstion 3700 of the Labor Code, 1 shall <br />forthwith c rnp y with those provisions, <br />Date: <br /> Signature: <br />Printed Name: <br />I <br />.. <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, <br />AND DAMAGES AS <br />PROVIDED FOR IN $ .gCTION 5706 OF THE LABOR CODE. <br />I, _ 10IP <br />/(C-57 I; onsed authorized represenintive), hereby <br />authorize <br />if il.44 4,11Lin _ <br />, <br />to sign this San Joaquin County <br />Well Permit Application on my behalf. i understand this authorization is valid for <br />one (1)Year arid' is limited toms %rod< pian dated on the frontage Of this at:°—It•--i"- , — — _---. <br />002 <br />wn?73.-i Nv7540l 6661770—C.:IL