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01/03/2003 14:18 209468' 3 FIFTH FLOOR PAGE 03 <br /> FEB 1 8 2003 <br /> San Joaquin County Environmental Health Department Unit IV Well Permit ApplicationuSupplement' <br /> JOB ADDRESS: 1)11 Novy DP-f ve PERMIT .SR#:^ <br /> 51t>ctLTot—1 ICA 952oZ <br /> LICENSED CONTRACTORS DECLARATIONL( CD) <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#: `7 1 -7 S t C, Expiration Date: ( � 3 i �d <br /> Date: , '-0 ) Contractor. ( _AS rC' s>E <br /> Signature Title:A IQ <br /> Printed name: y -'(SGL GST ✓V1 Gl V-\ <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 r1 1 policy numbers are: 1 (Policy Carrier: CAS I sv �� 0`n aNumber: AJ O�t <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 laws of California, and agree that if 1 <br /> should become subject to the workers'compensation provisions of Section 3700 of the Labor Code, I shall <br /> forthwith comply with <br /> htthose provisions. <br /> Date: c;�- `—]�� J Signature: <br /> Printed Name: -� G� �� A <br /> WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL,AND SHAILL SUBJECT <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 <br /> PROVIDED FOR IN SECTION 3706 OF THE LABOR COPE, <br /> AUTHORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> `J <br /> I, 6A_ _ C_\'1 \ GL,p (�A' Vr's"', Asignature oIC-57 licensed authorized representative), <br /> hereby authorize(print name) <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 /> 8.29.02/MI <br />