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02/22/2005 10:43 91686AV!t iSECOR `.r PAGE 02/02 <br /> 6ir 7>(r/ ZTZS <br /> r� <br /> San Joaquin County Environmental Health Department Unit IV Well Permit Application $u 1 me <br /> �CZcr�b aid spa f�Q7T� � <br /> JOB ADDRESS: '+3 PERMIT SR# __ nn gi (o!� <br /> �9J�S o r:K vy c f►.{, Yilv�l41&15 <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> I hereby affirm that I am licensed underthe provisions of Chapter 9(commencing with Section 7000)of Division <br /> 3 of the Business and Professions Code and my licenrm is in full force and effect. <br /> License #: Ct 7 Expiration Date: <br /> Date: -a/z Contractor:+ C.F' �i'f�l�i-'ty �Y-f 16 :5 <br /> Signature: A�, _1" erkany 4001 <br /> F <br /> Printed name. <br /> WORKERS'COMPENSATION DECLARATION <br /> I hereby sfEinrm under penalty of perjury one of the followino declarations: (CHECK ONE) <br /> I have and will maintain a certitloate of consent to pelf-insure for workers'compensation,as provided fpr <br /> by Section 3700 of the Labor Code,for the performance of the work for which this permit is Issued. <br /> 1 have and will maintain workers'compensation insurance,as required by Section 3700 of the Labor Code, <br /> for the performance of the work fvr which this permit is issued. My workers'compensation insurance <br /> carrier and policy numbers are: <br /> Carrier: Seto !i4if— Policy Number: <br /> I certify that in the porformance 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 Sectlan 3700 of the Labor Code, I shall <br /> forthwith comply with those provisions_ <br /> Expiration Date: . ignature <br /> rimed Name:o -�i� <br /> lc.. <br /> WARNING:FAILURE To SECURE WORKERS'COMPENSATION COVERAGE 1S 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 DAl1MA43ED AS <br /> PROVIDED FOR IN SECTION 3YO6 OF THE LABOR CODE. <br /> AUTHORIZATION FOR arH R THAN C-67 SIGNING PERMIT APPLICATION <br /> l & , (slgn8ture ofC-57 licensed authorized representative), <br /> hereby authorize(print name)3>0.Mg4 -J�r74,o in p'- 5b 9? '0? <br /> to sign this San Joaquin County Well Permit Application on my behalf. 1 understand this authorixativn In 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 I MI <br /> L•HO 29.02-DOI <br /> 6!22/04 <br /> Z0 39VcI DNI-nIa(l 993&D Z360CZC5Z6 8S:0Z 900Z/ZZ/Z0 <br />