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i <br /> 01/03/2003 14:18 2094683433 FIFTH FLOOR PAGE 03 <br /> L <br /> FEB 1 8 2003 <br /> San Joaquin County Environmental Health Department Unit IV Well Permit Application Supplement 1 <br /> JOB ADDRESS: NA\jy Da f Y6 PLRivil;,sit. <br /> PERMIT ,SR#: <br /> (r- F/-r' aF ///( /N.4,jY D/ZrvjF <br /> 's i C A 95 wz <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#: -1 1-751 O Expiration Date: <br /> Date: c -0 3 Contractor-. �gCA1J� Rtc_�-tr.lC� <br /> Signature Title' <br /> Printed name: L)419,�'O� C-V--\ CAL �1 <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 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 /> for the performance of the work for which this permit is issued. My workers'compensation insurance <br /> carrier and policy numbers are: + . 1 <br /> Carrier: 1'f , A S -,a N (17kT ej n O 1 Policy Number: © �` y" 5 >b S 3 <br /> 1 certify that in the perfornance 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 Califomia, and agree that if I <br /> should become subject to the workers'compensation provisions of ion 3700 of the Labor Code, I shall <br /> forthwith comply with those provisions. <br /> Date: c 3 Signature: e <br /> Printed Name: v-e 4 CA,_ C v\ o�, `-V-1\ v—*-- <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 /> (5100,000.),IN ADDITION TO THE COST OF COMPENSATION,INTEREST,ATTORNEY'S FEES,AND DAMAGES AS <br /> PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, <br /> AUTHORIZATION FOR OTHER THAN C-37 SIGNING PERMIT APPLICATION <br /> I, y e- r ck- C 0,42 JV1 Qy!--\ (signature ofC-57 licensed authorized representative), <br /> hereby authorize(print name) \A •G t V� O O�G� �('0C <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 /> B-29-02/MI <br />