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SUN-19-2008 03:36P FR0M:EHF'FIi-B 15305892230 TO: 19254260106 P.3 <br /> GONG/CGGO 10.1L \. i ItJIfuW 7 1J.]G.JOJLGOG • .,V.1a. I— <br /> San Joaquin County Environmental Health Department Unit IV Woll Permit Application Supplemerdal <br /> JQH ADDRESS: X31 CA(ULyA) wEb7m1l '3LV9 PERMIT SR# <br /> 57uG�r7uJ, CA <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 Prrrfesslons Code and my license is in full force and effect. <br /> Licen .9#: C S 7 777 ' Exp Date: A.b°/ ° <br /> Date: 6//./o X _ Contractor <br /> Signature: Title: <br /> i <br /> PrintName: �nv✓FS O'f� <br /> WOhKER'S COMPENSATION DECLARATION <br /> I hereby affirm under penalty of pe rpury one of the following declarations: (check one) <br /> I 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 /> prarmjt is issued. <br /> LI have and will maintain workers! compensation insurance, as required by Section 3700 of the <br /> Labor Code, for the perfcrmance of the work for which this permit is issued. My workers' <br /> compensation insurance carrier and policv numbersare: ++ <br /> Carrier:.Sfnk rUAJ0 C'o,a,e 7uS Policy Number:000 s -2oo d <br /> I certify that in thu performance of the work for which this permit is issued, I shall not employ any <br /> ! person in any manner so es to become subject to the workers' compensation law of California, and <br /> agree that if I should be,:,wne subject to workers' compensation provisions of Section 3700 of the <br /> Labor Code, I shall forth:v 141 comply With those provision t, <br /> Exp. Date: ° " ° _°8 �_� Signature: / <br /> Print Name: <br /> WARNING:FAILURE TO SECURE WORKF%S•COMPENSATIOW COVERAGE tS UNLAWFUL,ANO 5tiALL SUtWeCT AN EMFLOYeRTO <br /> CRIMINAL PENALTIES AND CaVfl.FINES UP TO IiiOG,000,IN ADDITION TO THE 6oST OF COMPENSATION,INTEREST, <br /> ATTORNEY'S FEES,AND DAN!GES A5 PROVIDED FOR IN SECTION J70a OF THE LA90R OODe. <br /> AUTHOR ZATIONC! ER THAN C-57 SIGNING PERMIT APPLICATION <br /> I, vt S a L,—_,_ (signature of C-57 licensed authorized repro sentatke). <br /> hereby authoriza(print name) 3 irdAt ry /}5 i 6 &1244kydwiro ,to <br /> sign this San Joaquin county Well Permit Application on my behalf. I understand this authorization Is valid <br /> for one year and is limited to the�i vrk plan dated on tho front pago of this application. <br /> V.CU.PGNYff A.oP <br /> E102041 nlaR7 <br />