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12, P5 aw/06 <br /> 3 6 P5 oN <br /> �Z o� <br /> Stanislaus County Environmental Health Department Well Permit Application Supplement <br /> JOB ADDRESS: t9 Z 00 PERMIT SR#: 00=7-5 <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#: --',14 Expiration Date: /2 <br /> Date: v/ b Contractor: ;2eso N ANT- SU of C- — 11,� 6- <br /> Signature: ( I ' Titlelktz- <br /> Printed name:�/r tit',nt�LelL9 i ._ <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 are: <br /> Carrier: 5) r4� ,e 5,r, A 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: 1,7-1)101 Signature: 2 0 l <br /> Printed Name: TD,,n 6A :nQ 17jL(ti <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( RIZATIO FOR OTHER THAN C-`57 SIGNING PERMIT APPLICATION <br /> e 1 (signature ofC-57 licensed authorized representative), <br /> hereby authorize(p t name) Raynold I.Kablanow II ✓✓✓ , <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 />