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Sent By: HP LaserJet 3100, JetSuite; 19-Aug-08 16:04; Page 1 /1 <br /> ! f! <br /> L,v/ zoub 14:08 9256851' HULTGREN-TILLIS PAGE 01/01 <br /> W Z 3q <br /> San Joaquin County Environmental Health Department Unit IV Well Permit Application Supplemental <br /> JOS ADbR �acoh I� 3 T�3_�_ 3 i PERMIT SR of 055 1 8 <br /> ESS: tfww <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> i hereby affirm that I am licensed under the provisions of Chapter 9(commencing with Section 7000)of <br /> Division 3 of the Business and Professions Code and my license Is in ful'force and effect. <br /> License <br /> Date: ____-__--- --- <br /> Date: � � _-- -_ Contractor: 77 <br /> Signature: 4 / � Title: <br /> Print Mame:_ <br /> WORKER'S COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the following declarations: f check one) <br /> ( have and will maintain a certificate of consent to self-insure for workers'compensation, as <br /> provided for by section 3700 of the labor Code;for the performance of the work for which this <br /> permit is issued. <br /> ! have and will maintain workers' compensation insurance,as required by Section 3700 of the <br /> Labor Code, for the performance of the work for which this permit is Issued. My workers' <br /> compensation insurance carrier and policy numbers are: <br /> Policy Dumber: <br /> I certify that in the performance of the work for which this permit is issued, I shell not employ any <br /> person in any manner so as to become subject to the workers'coripensation law of California,and <br /> agree that if I should become subject to workers'compensation provisions of Section 3700 of the <br /> Labor Code, I shall forthwith comply with those provisI <br /> Exp. Date; _ _ Signature: <br /> Print Name: <br /> WARNING:FAILURE TO SECURE WORKERS'COMPEN$ATION COVERAGE 13 UNLAWFUL,AND SHALL SUBJECT AN EMPLOYER TO <br /> CRIMINAL PENALTIES AND CiVIL FINES UP TO$100,000,IN ADDITION TO THE COST OF COMPENSATION,INTEREST, <br /> ATTORNEY'$FEES,AND DAMAGES AS PROVIDED FOR iN SECTION 3706 OF THE i.ABOR CODE. <br /> AUTHORIZATION FOR OTHER THAN C-$7 SiGNiNG PERMIT APPLICATION <br /> (signature of C-57 Ilcensod authorized representative), <br /> hereby authorize (print name) +_W - �GY�G{`C��.�w_- , to <br /> Sion this San Joaquin county Wall Permit Application on my behalf. I underg.tand this authorization is valid <br /> for one year end is limited t he work plan dated on <br /> frontpageof this application. <br /> EHn 1&Ot 1115/07 WELL.PERMIT APP <br />