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San Joaquin County Environmental Health Department Unit IV Well Permit Application Supplement <br />/003(0 4/2,7 <br />JOB ADDRESS: sC2-1 0/11401A- PERMIT SR#: (DON9/33 <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 #: (p?) Expiration Date: <br />Date: 2.---11-oLA Contractor: Aa .wone e tk ever, E vvN) c cviuem-1--0.1 <br />Signature: <br />qVAd4-' <br />Printed name: Ety-42A,A.e_ <br /> <br />Title: e-rebic9csi- <br /> <br />WORKERS' COMPENSATION DECLARATION <br />r' <br />I hereby affirm under penalty of perjury one of the following declarations: (CHECK ONE) <br />I have and will maintain a certificate of consent to self-insure for workers' compensation, as provided for <br />by Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. <br />t•Zi 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: )k-a-'Ve._ evtAApe-W-1)--k-i c ,..v‘A Policy Number: <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 <br />should become subject to the workers' compensation provisions of Section 3700 of the Labor Ccde, I shall <br />forthwith comply with those provisions. <br />CkrA,Le <br />Printed Name: (-51,1e AQ <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 />AUTHORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> (signature ofC-57 licensed authorized representative), <br />hereby authorize (print name) <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 />8-29-02 / MI <br />1'31 IL( <br />Date: Signature: