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IZ 6 PS cW/0 F-6 <br /> 3 6 Pt, oN <br /> 12 05 <br /> Stanislaus County Environmental Health Department Well Permit Application Supplement <br /> JOB ADDRESS: Z OrJ�pERMIT SR#:l <br /> *• 1b OFFS I <br /> JJ 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#: Expiration Date: /Z <br /> Date: Contractor.- Re$a N —sC- <br /> _ <br /> Signature: I CTt' <br /> Title•Viu, P",:,A <br /> Printed name:�� �, � Lela ��� 1 <br /> U <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 /> 1 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 are: <br /> Carrier:—S�rA 6- En I Policy Number: <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. —� <br /> Expiration Date: L7-11 G Signature: I, <br /> Printed Name: C::)�A <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 3706 OF THE LABOR CODE. <br /> AUT W RIZATIO FOR OTHER THAN C--57 SIGNING PERMIT APPLICATION <br /> 1' o (signature ofC-57 licensed authorized representative), <br /> hereby authorize(p t name)_Raynold 1.Kablanow 11 ✓✓✓ <br /> to sign this Stanislaus 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 /> EHD 29-02-001 <br /> 6/22/04 <br />