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12/07/2004 09:54 9168610430 SECO^R .a PAGE 02/04 <br /> jfq�[q m /6 �' �� <br /> CIS, /Ud � Z <br /> San Joaquin County Environmental Health Department Unit IV Well Permit Application Supplement <br /> JOB ADDRESS: /(o2e0 Co lx;�Ioe t •�+Lag-( PERMIT SWO/9 Y0 7� <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#: D1 00 7 9 C-S 7 Expirstlon Date: —? - 31 '-06 <br /> Date: 04 04 ,, Contractor, rAAjnC)(AAQzAr_V_i11mqC� 6, <br /> Signature: C. 15E- -��--�Tkle; /rw. <br /> Printed name: C_ i rd G E t4.)D D D W <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the following derJaraticns: (CHECK ONE) <br /> _1 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 /> ?>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'compensadon Insurance <br /> carrier and policy numbers are: <br /> Carrier: �- _Policy Number. n U LA C C U- b Q S <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 became 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 o1 the Labor Code, I shall <br /> forthwith comply wfth those provisions. <br /> Expiration Date: D�ds-_Signature:_ ------ <br /> Printed Name;_ CO—LJ�_7� C W 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 /> ($100,000.),IN ADDITION TO THE Cosi OF COMPENSATION,INTEREST,ATTORNEY'S FEES,AND DAMAGES A9 <br /> PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. <br /> AUTHORIZATION FOR 0THE THAN C•57 SIGNING PERMIT APPLICATION <br /> ,,(lsignature ofC-S7 licensed allthortzed representative), <br /> hLO-29-021 <br /> bauthorize(print name) M 'T � — TZ to thin San Joaquin County Well Pormlt Application on my behalf. I understand thla authorisation Is valid for <br /> year and Is limited to the work plan dated on the front page of this application. <br /> MI <br /> E14029-02-00: <br /> 6R2101 <br /> Z00 in NuTTTTuO Puamp00h 00£6bL£LOL XVd TT:TT x009/L0/9T <br />