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TUN-23-2004 07:23P FROM:ALL4,1c'LL ABRNDONMENT 1(530(644-1439 J:19169392172 P.2 <br /> 01/1II21787 lb:154 1 rrt ax <br /> �.: ►iUKiLUN <br /> San Joaquin Cqunty Environmental Health Department[Unit IV Well Permit Application Supplement <br /> JOB ADDRESS: ZZS ou A a�fi� <br /> PERMIT SRiIR:_.`�__ <br /> r.+tGtavt t* 9 raze W <br /> . LICENSED CONTRACTORS DECLARATION ( CSL ) <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 Cade and my license Is In full fume and effect. <br /> License# � ,� -- _ Expiration Date: <br /> i <br /> ' 1 �� <br /> Date-, I/1 lblm—) Contrac#or: <br /> Signature: '� + .Title: � T <br /> Printed name: d <br /> WOIkKERS' COMPENSATION DECLARATION <br /> I hereby arm under penalty of pejury one of the following declarations: (CHECK ONE) <br /> I have and will maintain a Certificate of consent to seif4mure 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 /> 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 n mbera are: <br /> Carrier. ' ( 1' 1 r Volley Number. <br /> I <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, d <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 /> (9 00,000.),IN A113101TION TO THE COST Or COMPENSATION,INTEREST,ATTORNEY'S FEES,AND DAMAGES AS <br /> PROVIDED FOR IN$ CTION 3708 OF THE LABOR Cone. � <br /> AUTHORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> I. AlwzlAm 010W gnature ofC-57 licensed authorized repreaentotfvel, <br /> or <br /> hebraby authorise(ptint name) lG- C*DM-?,�M �1M0_-Wof <br /> to sign this son.Joaquin County Weli 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 opplicRlion, <br /> 9-29-021 MI <br />