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153058922--9 - TO-19256024720 PAGE <br /> OCT-18-2007 02:53P FROM:ENPROB ET; &641NEERING P' <br /> 10/18/2097 14:17 19256924'44.e <br /> San JoaquM COu]nty Environmental Health Dsparlment Unit N Well Permit ApPIIcaU+)n guPPiemertt <br /> JOB ADDRESS,17/7 S(PpTol'Jh °~ PERMIT SRO: �7y -- <br /> LICENSED CONTRACTORS DECLARATION LCD <br /> 3 offtthe 13ug nlnl ethat <br /> ,aI am licensed under the nd Prolessios Code and my I censoe is inffull fo Ana gam With section 7000)of Division <br /> e_s� �7,7r�o Explrmion Data: <br /> L•wronce M:, <br /> .in <br /> Date:./¢�� Contractor. � / — "• <br /> Signature: �r Tale: �`��s'� <br /> Printed name: <br /> WORKERS, COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the rallowing declarations: (CHECK ONE) <br /> ensation,as <br /> by Se tion 37000 ofand vAU fntain a the Labor Code.for catO of the performance of the work which this Pemrit is Issued. <br /> ed for <br /> as required <br /> Section 3700 of <br /> e Labor <br /> for the parte ve and irnence offn workers'the work for which this permit is Isson ued. My workers!compensation�insuranceCode, <br /> carrier and policy numbers are: <br /> Carrier: ,� 'S' Policy Number: 'W44— _ oZCE1 <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 taws of California,and agree that If I <br /> should become subject to the workers'compenealkn provisions of Section 3700 of the Labor Code,l shall <br /> forthwith complywith those provisions, <br /> ExplratkmDate:I it/D Signature: --- <br /> PrlMed Name: <br /> WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT <br /> YER <br /> AN EMPLOTO CRIMINAL PENALTIES AND CIVIL PINES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> PSROHID®FOR ADDITION <br /> �To iON 87E OF OF COMPENSATION, <br /> ON,INTEREST,ATTORNErS FEES,AND DAMAGES AS <br /> AUTHORIZATION FOR OTHER THAN C-67 SIGNING PERMIT APPLICATION <br /> 1 i7- - 40 (signature ofC-67 licensed authorized representative), <br /> , <br /> hereby authorize(pAM name <br /> to sign this Son Joaquin County Wall Permit Application on my behalf. 1 understand this atmOrb On ie valid for <br /> one(1)year and is limbed to the work plan dated on the front page of fhla appliation- <br /> 8•ZB•02!MI <br /> arm 2o.otaa <br /> eravoa <br />