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Nov 17 06 10 : 49a Mitr--L711 Drilling 707 - ^ 44 - 9049 p . 204 <br /> Nov . 17 . 2006 11 : 39AM Ao . anced Geoinvii0anentdl No . 6623 P. 2 <br /> 70 <br /> San Joaquin County Environmental Health Department Unit N Weil Permit Appoca on Supplement <br /> JOB ADDRESS:J? htl �C4 171 . .l L PERMIT SR#: <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 #: G' - 56 7 Z 6 ( 7 Expiration Date: 6 .' y 107 <br /> Date 1 t Z ( 7 f o 6 Contractor. <br /> Signature: Title: y r <br /> Printed name: G G <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the following declarations: (CHECK ONE) <br /> _ I have and will maintain a certificate of consent to setf4risure 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 /> . M workers' compensation insurance <br /> for the performance of the work for which this permit is issued y p <br /> camler and policy numbers are: <br /> Carrier: �L-f FD� V�. - I j 5 . Gv .. Policy Number. 4 b — ° 7756 ) — of - p 2 <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 provisions of Section 3700 of the Labor Code, I shall <br /> forthwith comply with those provisions. <br /> 7 <br /> Expiration Date: G L 0 / Signature: '- <br /> PrintedName: <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 /> ($10010119J, IN AUDITION TO THE COST OF COMPENSATION, INTEREST, ATTORNEY'S FEES, AND DAMAGES AS <br /> PROVIDED FOR IN SECTION 5706 OF THE LABOR CODE, <br /> AUTHORIZATION FOR OTII15R THAN C47 SIGNING PERMIT APPLICATION <br /> // ,�t p (signatu otC5711censed authorized representative), <br /> LA <br /> hereby authorize (print name) J �5 / - ^ U 6<�f� d <br /> J <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 /> 849-02 1 <br /> pplication_8-29-021 MI <br /> EHD 29-02-901 <br />