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Apr . 2 . . 2006 3 : 37PVi ; vanced GeoEnvironmeriai No . 4674 P , 2 /2 <br /> San Joaquin County Environmental Health Department Unit IV Well Permit Application supplement <br /> JOB ADDRESS: f 201 S CMk4ee3)— ] hYPERMIT 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 farce and effect <br /> License #: �D 5 O L4 Q 2 Expiration Date: i S I U co <br /> Date: 4 t( 2 Contractgr, (n I L� ' I I f l �✓^ L"rlh <br /> Signature: 1 ^� !� \. 1i,,t J . ;,. Title: (r )F"i . .�Y <br /> Printed name: M ✓ L� jtk- ` c4i e bL <br /> I � <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 self•insure for workers' compensation, as provided for <br /> by Sec ion 3700 of die Labor Code, for the performance of the work for which this permit is issued. <br /> ! 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' compensation insurance <br /> carder and policy numbers are: <br /> Carrier: S -etJ.h f t V% .-:�1 Policy Number: _ I� I `7 � C� 7 :> ,:/ �0 / J <br /> I certify that in the performance of the work for which this permit is issued, I shall net 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' compensagon provisions of Section 3700 of the Labor Code, I shat <br /> forthwith comply with those provisions. <br /> � �( Q <br /> i Expiration Date: Signature: <br /> Printed Name: lu G(.ri. l <br /> WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL SU6JECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> (;100,000.), IN ADDITION TO THE COST OF COMPENSATION, INTEREST, ATTORNEY'S FEES, AND DAMAGES AS j <br /> PROVIDED FOR IN SECTION 3708 Of THE LABOR CODE, <br /> AUTHORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> (Signature <br /> �afC-57licensed authorized representative), <br /> . hereby authorize (printnam¢) Alva I <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 an the Trent page of this application, <br /> 8-29.021 Ml <br /> F DJ 19-0]-001 <br /> 6/2204 <br />