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SEP-10-03 WED 09 : 17 AM ENPROD 9165892230 P. 02 <br /> 0 <br /> og/0.9✓2003 1,6:14 FAX 925 943 2366 GEOSYNTEC-WO Z002 <br /> San 4 <br /> oaquin County Environmental Health Department Unit IV Well Permit Application Suppiement <br /> / PERMIT SR#: <br /> JOB ADDRF-5s. 9 Q� - -- <br /> LICENSED CONTRACTORS DECLARATION (ICD) <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 efffe�ec`�t�� <br /> License#: Z 0Q _ -Expiration Date' <br /> Date: Con acto : f— �i'✓✓//ZT3ft�i71��� )+�1'tJ _ <br /> Signature: <br /> Printed name: <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm under penalty of p©rjury one of the following declarations: (CHECK ONE) <br /> I have and will maintain a certifloate 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 /> 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 /> carrlor and polic numbers are: <br /> Carrier- _ , Policy Number: W4 <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 pr ons of Section 3700 of the Labor Code, I shall <br /> forthwith co ply with those provisions. <br /> I <br /> Date: 9 Signature: <br /> Printed Name: <br /> WARNING: FAILURE To SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL.,AND SHALL SU13JECT <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 /> ofC.57 licensed authorized representative), <br /> hereby authorize(print <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 /> L 8-29,021 Ml <br />