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y Al ' <br /> ■�wJr I f <br /> r14 <br /> San Joaquin County Environmental Health'-Departanent Unit N Well Permit Application Supplementai,r <br /> si ' t J / <br /> JOB ADDREss: 2360 East Avenue=Tracy; CA PERMIT SR# <br /> LICENSED CONTRACTORS DECLARATION (LCD) ;! <br /> l i I� lil . <br /> I hereby affirm that I am licensed under le srovisions of Chapter 9(coMmencing with Section 7000)Of. <br /> Division 3 of the Business and Professio6si',Code and my license is in full force and effect. IE <br /> �1 <br /> E; <br /> License#: $$3865 ! T 1�, Exp Date: 1(31/2012 <br /> Date: <br /> 03108120'10 ''Contractor. Fisch Drilling ; �p <br /> �b1 � a ;N <br /> Signature: Title: Owner <br /> Print Name: David Fisch <br /> WORICER'.S COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury oFne;of the following declarations:(check one) <br /> i <br /> I have and will maintain a certifidaof consent to self-insure for workers'compensation,as !° i <br /> provided for by section 3700 of the 1 bor Code, for the performance of the work for which this !! <br /> permit is issued. "' <br /> i € 3 <br /> I have and Wil maintain workers`y'co� ensation insurance,as required by Section 3700 of the <br /> I Labor Code,for the performance'o'f the work for which this permit is issued_ My workers' ' <br /> i 41compensation insurance carrier. lriillpolic'y <br /> polity numbers are- <br /> - <br /> State <br /> II I <br /> State Comp Ins 111 Number• 010825-09Carrier• F <br /> work for.which this permit is issued, I shall not employ any <br /> I certify that in the performance o!f the p 'r <br /> person in any manner so as to bed&he subject to the workers compensation law of Califomia,`andP <br /> agree that if I should become sutiject!to workers`compensation provisions of Section 3700 of the <br /> Labor Code, I shall forthwith con piyl.with; those provisions. ! <br /> Exp. Date•$/2 10 I[Signature: <br /> kit i David Fisch i. <br /> Print Name: I <br /> WARNING:FAILURE TO SECURE WORKERS'C01dIPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT AN EMPLOYER-TO <br /> CRIMINAL PENALTIES AND CML FINES $10% <br /> UPIQ00 IN ADDITION.TO THE COST OF COMPENSATION,iNTEREST,:. <br /> ATTORNEY'S FEES,ANC DAMAGES AS�PROV1DED FOR IN SECTION 3706 OF THE LABOR CODE. i' ( ?! <br /> UTHORIZATION FOR OTHER THAN C-57 SIGNING'IPERMIT APPLICATION <br /> I, l "l !! 3 (signature of C-57 licensed authorized representative), it Jk <br /> w ;� <br /> hereby authorize(print nam) Jahn P L831B;. Lee.& Pierce, Inc. .to <br /> sign this San Joaquin county Well Permit Application on my behalf. I uriderstand this authorization is valid <br /> for one year and is limited to the work plan-Zed on the front-page of this application. <br /> 812SM21MI <br /> 1M. !1 ! 1 <br /> END 2901 1115W YYCLL VERRIIT APP I, <br /> ,E. <br />