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l <br /> i <br /> sU ; aaue IUU424 FA1 0nae (5759 rr:.SiARER 1 : a, rxI ; . ivkhuo2 <br /> . Pi <br /> goy <br /> San Joaquin County Environmental �Htplth Department Unit ivwell Permit Appiftatio(nn up Isment <br /> JOB ADd DRESS: 1"/ i ( --- - . -- 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 #, I? I q '{ It & 90ragan Date: 6C ' Y1 07 <br /> Date: Contractor. rsr� I�rrMuch � a.r.0-r..4 C ,,.J aQ� • �GrSr"•�M-wN' /cL ..•L <br /> Signature: TRW 14-''J'&0% <br /> Printednam4irr + 1A- ddb/ hr <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby 'af8rm under penalty of perjury one of tha tollowing declarations; (CHECK ONE) <br /> I have and will maintain a oerlificate of consent to self-insure for workere' compensation, as provided for <br /> by Section 9700 of the Labor Code, for the performance of the work for which this permit Is issued. <br /> ✓EI have and vAll maintain Workers' compensation insurance, as required by Section 370D of the Labor Code, <br /> for the performance of the work for which this permit Is Issued. My workers' compensation insurance <br /> carrier and policy numbers are: <br /> Carrier: /�S F _ Polioy Number: .T R W t& V KAA 7J 31 <br /> I certify that in the perfomrance 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' compensatkin laws of California, and agree that if 1 <br /> should hecome subject to the workers' compensation provisions of Section 3700 of the Labor Code, I shall <br /> forthwith comply with those provisions. <br /> Expiration Date: s�• of • 6�,_ Signature: <br /> Printed Name <br /> WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL SU6JEC7 <br /> AN EMPLOYER TO CRIMINAL PENALT155 AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> (siee,oaa), IN ADDITION TO THE COST OF cOMPFNSATION, INT6RFsT, ATTORNEY'S FEES, AND DAMAGES AS <br /> PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, <br /> AUTHORIZATION FOR THAN C-57 SIGNING PERMIT APPLICATION <br /> (signature ofC•67 licensed autharlrW representative), <br /> hereby authorize (print nam <br /> to sign this San Joaquin County Well Permit Application on my behalL 1 understand this authorization is valor for <br /> one (1 ) year and is limited to the Work plan dated on the front page of this applitation. <br /> 5-29.OZI MI _ <br /> Elm 29-02401 <br /> 6=04 <br />