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05/10/2005 10: 34 53068280` 9 WDC EXPLORATIO PAGE 02 <br /> 05/10/2005 08;54 PAX 208 94ti1 002 <br /> San Joaquin Countynvironinental hk?alth Department Unit IV Well Parinit Application SUpplernant <br /> ��/ <br /> JOB ADDRESS:pOx// �C6+�n PERMIT SR#: Dd Zz 33 <br /> 01U •Saf�.Jry <br /> LICENSED CON CTORS DIECL/C ON (LCD) <br /> I hereby affirm that I am licensed under the provisions of Chapter 9 (commencing with Section 7000)of Divleion <br /> 3 of the Business and Professions Code and my license is In full farce and effect. <br /> Licenge 9 a 3 3 21 Expiration Date; d (0/30 / 200 <br /> Date; Jr" 10 ' 2�5' Contractor: <br /> 9lgnature� Title: i'4-1 6G �$ IUatQq <br /> Printed name: rPVI <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 am: /1 <br /> Carrier: tie' " LAI,-, Policy Number: W?` Do0rD I L( Q.O <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 I <br /> should become subject to the workers'compensation provisions of Section 3700 of the Labor Code, I shall <br /> forthwith comply with those provisions, �J <br /> Expiration Date; I "<ca` signature: <br /> PrintedNamet {C�NV1� I� r7 • �00�`� <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 /> (Stdg,e00J,IN ADDITION TO THE COST OP COMPENSATION,INTEREST,ATTORNEY'S FEES,AND DAMAGES AS <br /> PROVIDED FOR IN SECTION 3708 OF THE LABOR CODE, <br /> AUTHORIZATION FOR OT ER THAN C-57 SIGNING PERMIT APPLICATION <br /> r � > (signature ofC-57 licensed <br /> /authorized representative), <br /> hereby authorize(print name) 4 <br /> to sign this San Joaquin County Well P?rtoit Apptloetion on my beholf. I understand this authorisation Is valid for <br /> one(1)year and is limited to the work plan dated On the front page of this application. <br /> 8-29.021 MI <br /> ERD 29-02-001 <br /> 6122/04 <br /> 05/10/2005 TUE 10:32 ITX/RX NO 56111 0 002 <br />