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05105/2008 17. 19 2095224227 GEOLOGICAL TECHNICS PAGE 03/93 <br /> I <br /> i <br /> is <br /> is <br /> Sean Joaquin County Environtn¢ntW Health Ild�psrbrlent Unit IV Well Perrnit Appllcaltion Supplement <br /> JOB ADDRESS: 1, PERMIT SRO: <br /> LICENSED CONTRAORS DECLARATION LCD <br /> I hereby affirm that I am licensed under the provial"of Chapter 9(commenting with SeCUOn 7O)of Division <br /> 3 of the Business and Professions Code and my IJ+nss is in full force and effect <br /> f <br /> License#: �cl�y� Expiration Date: 3' I-1 a <br /> Data: Contractor: !+crA-A 1.1 <br /> d � <br /> 519natum: cJ Title:_ <br /> Prlr*W name: <br /> WORKERS'COM NSATION DECLARATION <br /> I hereby eAflrm under penolty of perjury one of the'61!awing declarations: (CHECK ONE) <br /> _I ha+►e and will maintain a certificate of eorrsehi.to self4nsure for workers'compensation,as provided for <br /> by Section 3700 of the Labor Code,for the pe tarmartce of the work for which this permit is issued, <br /> it <br /> I have and will maintain workers'contpensat - insuratnce.as required by Section 3700 of the Labor Code, <br /> for the perforrnance of the worts for whkh thi; is issued. My workers'compensation insurance <br /> carrier andIlc�num6ers e: <br /> C IC I VARA�L:. <br /> Corder: Lr Az 1L_ r S. . Z,t1C925V550 t <br /> Paliey Numbwr. <br /> I ae tify that in the perforrnan ce of the work 1`4 ich this permit is issued,1 shall not ernploy any person in <br /> any mwner so as to become subject to the , rs'compensation laws of California,and agree that If i <br /> should become subject b the workers' compel. ation provisions of Section 3100 of the Labor Cade, I shall <br /> forthwith comply with those provisions. I e <br /> ExplrstIon Dallt►;D AQ l.' '-�'9jgnaturo•___;;+ �/ <br /> Prl ntod Name: <br /> WARMNR:FAILURE TO SECURE WORKERS'COM NSATION COVERAGE tS UNLAWFUL,AND SHALL SUBJECT <br /> AN EMPLOYER TO CRIMINAL PENALTRme AND c FMES UP TO ONE HUND14ED THOUSAND DOLLARS <br /> {;1t1Q,00d,),IN ACDMOK Tl!TNF COST OF COMP% TIOlf,INTEREST,ATTORNEY'S FF S,AND DAMAGES A9 <br /> VI <br /> PRODED FOR IN 3ECrION 3706 OF THE LABOR DE. <br /> p <br /> AUTHORIZATION FORO, THEA TOAN C-57' SIGNING PERMIT APPLICATION <br /> I, r s "S�1•� ,T� {slgnedure ofC-57 Ikenewd authorized representative), <br /> ii r• <br /> hereby autherhm(print nems)_ <br /> to sign this San Joaquin Caumty Welt Porrnit Applilt+n an nny behalf. 1 rndersUnd this stMorizatlon is volld for <br /> ere(1)year and Is"god to the worlt plan dated orf�a from page of this aipp%=tion. <br /> i-211.02 f 0 <br /> EXI)2M240i <br /> I� <br /> £'d 6tiLS-i3£9-96f; daoC Oulllp(] eolaewV1sel Eh0:60 90 90 ABN <br /> k <br />