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• <br /> Noy. 15- 2005 9:50AM Advanced Geotnvi rorlmentai +uo. jy44 r. - <br /> Sart,Joaquin County Environmental Health Department Unit IV Well Kermit Application Supplement <br /> JOB ADDR1=SS: �j1�� a � PERMIT SR#: <br /> LICENSED CONTRACTORS DECL.AkATION (LCD <br /> 1 hereby affirm that I am iirensed under the provisions of Chapter S(comMeheing with Seotion 7000)of Division <br /> 3 of the Businass and Professions Code and my license Is,in full force and effect. <br /> License�_��'� �' �Jlr�{� E#irstlon bate: ;;``��� 4 � --- <br /> Data: /I"• CAnit7lCtor �,,�- <br /> V Ai <br /> Signature: Title: <br /> Printed name: sent-LE-L-0 Irac� -- <br /> WORKERV OOMPENSATION DECLARATION <br /> I hereby'affirm under penalty of perjury one of the following declarations: (CHECK ONE) <br /> 1 have and will MAintain a aarbfirata of consent to self-Insure for workers'compensation,as providod for <br /> by Section S7OO of the Labor Cods,for the performance of the work for which this permit is issued. <br /> _I have and will maintain workers'compensation Insurance, as regtllrsd by Section 3700 of the Labor C6do, <br /> for the performance of the work for which this permit is rued. My works rs'compensation insurance <br /> caner and policy numbers a e. <br /> Carrier: !`Z oNs k L _ tQ Q�,Policy Number: <br /> --r <br /> 1 certliS that in the performance of the work for which this permit is itrued,t shell not employ any person In <br /> any manner so as to become subject to Mo workers'compensation laws of Caltfomia,and agree that lf'I <br /> should becorne st bittt to the workers'oompenestich provisions of Section 3700 of the Labor Gods,l©hall <br /> forthwith Comply with!hose provisions. , <br /> Expiration bate-�- Signature, 1 __ <br /> PrintedNAme• � t+r_�r�Q, f <br /> WARNINt:PAILUftE TO,9PCURI;U 0PJ(EIg30 COMPENSATION COVERAGE IS UNLAWFUL.AND SHALL SUBJECT <br /> AN!EMPLOYER TO CRIMINAL PENALTIES AND CIVIL F1NIES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> IN ADDITION TO THE COs7 OF COMPENSATION,INTIaKF-S-t,ATTORNEY'S FEES,AND DAINAG93 AS <br /> PROVIDED FOR IN SECTION 3706 OF THE I-ADOR'CODE, <br /> AUTHORIZATIO F R OTNO THAN CZ7 SIGNING PERMIT APPLICATION <br /> !, {signaturo of0.67 licensed authorized,representaf;ve), <br /> hereby authorize(print name)__ W I I" cam,,. <br /> to sign this San Joaiquin County Well Permit Appiicatton on my behalf. I undelsta111q tnts authorization Is valid for <br /> One(1)ymir and Is 111nited to the work piaAn dited an the front page of this application. <br /> 8-29.021 MI <br /> EilDz9•oyoor <br /> bf�z104 <br />