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02/22/2005 10:43 916a61b1*10 SECOR .Anse PAGE 02/02 <br /> San Joaquin County Environmental Health Department Unit IV Well Permit Application S(u� I men <br /> 6)C x Ct bsp t•~d�(Z�9 AY f ern <br /> JOB ADDRESS:_ z-t 33 c-0�_,,,c ttiy n,.,r _ PERMIT SRO <br /> __ i►�C� S[/ !o! <br /> ,�--� <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 #: C S 7 tG' Expiration Date:___ <br /> Date: Contractor.6 e" <br /> Signature: / Title(�CIz?�rdl� fY�Cti�G <br /> Printed name.C XL2r& ft�1r <br /> WORKIERS'COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the followin0 declarations: (CHECK ONE) <br /> _I have and will maintain a cerilfioete 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 <br /> are: p v ll <br /> Carrier: Sc?e7�rrQh�' Policy Number: ex l o `f' o Get <br /> I <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$700 of the Labor Code, I shelf <br /> forthwith comply with those provisions. <br /> Expiration Date: ignature: ----- M _ <br /> g DI ��rinted Name: <br /> � OK- <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.),1N ADDITION TO THE COST OF COMPENSATION,INTEREST,ATTORNEY'S FEES,AND bAMAQEB AS <br /> PROVIDED FOR IN SECTION 3706 OF TK9 LABOR CODE. <br /> AUTHORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> I, 4& (signature ofC•57 licensee authorized representative), <br /> hereby authorize(print name}_ af: Q4 -J�r oW v, 0k- !a 97C O4L J!R ft e m a 1100-t f <br /> to sign this San Joaquin County Well Permit Application on my behalf- I understand this authvNt¢atidn b valid far <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 /> 11140 29.02.001 <br /> 6/22 O4 / <br /> Z0 39dd DNI-nIa(l 99389 ZOEOETE5Z6 SS=OT SOOZ/ZZ/ZO <br />