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01/07/2004 10:21 91696 0430 SECOR PAGE 02/02 <br /> 9 C,oT'5 15uiE; 3 <br /> San Joaquin County Environmental <br /> qalth DepartmentUnit IV Well Permit Application Suppplethi <br /> JOB ADDRESS:(O 3 ( 0 !� PERMIT SR#: oiI r/ <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> I hereby affirm that I am licensed unde,the provisions of Chapter 9(commencing with Section 7000) of Division <br /> 3 of the Business and Profession$Code and my license is In full force and effect. <br /> License# CS? YdS/�,f_ Expiration Date.1- � 176 <br /> Data: pit Contractor.� �r���'� it 1�� <br /> signature:�S. �' ,/ilwe Title: Tjd%t�' tip <br /> Printed name: <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the following declarations. (CHECK ONE) <br /> I have and w11 maintain a certificate of consent to self-Insure for workerscompensation,as provided for <br /> by Sactlon 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 his Permit is issued My workers'compensation insurance <br /> carrier and policy numbers are: <br /> Carrier: 6's"? Policy Number: Q 1P <br /> I certify that in the performance of the work for which this permit is issued, 1 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 370 of the Labor Code, 1 shall <br /> forthwith comply with those provisions. <br /> Date: 0//Oz/m/ Signature: <br /> r <br /> Printed Name: <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 /> ($100,000.),IN ADDITION TO THE COST OF COMPENSATION,INTEREST,ATTORNEY'S FEES,AND DAMAGES AS <br /> PROVIDED FOR IN SECTION 37De OF THE LABOR CODE. <br /> AUTHORIZATION FO/R OTHE TH C-57 <br /> .5g7SIGN5licensed <br /> INGPERMIIT APPLICATION <br /> TIION�t Ve)I <br /> I ,�ItftOet9Prfrunri/��Z.lbf�i� Lf'lwi. <br /> hereby authorize(print name) Roy -161f CCAAIV <br /> to sign this San Joaquin County Well Permit Application on my tmJ I understand this authorization Is valid for <br /> ane(1)year and Is limited to the work plan dated on the front page of this application. <br /> 6-29-021 MI <br /> 2 d OOZE 1317?J3SH-11 dH Nd02 :6 6002 80 NUC <br />