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San Joaquin County Environmental Health Department Unit IV Well Permit Application Supplemental <br /> JOS ADDRESS: 2360 East Avenue, Tracy, CA PERMIT SR# 0:2 / 5.�Z <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> I hereby affirm that I am licensed under the provisions of Chapter 9(commencing with Section 7000)of <br /> Division 3 of the Business and Professions Code and my license is in full force and effect. <br /> License#: 683865 Exp Date: 1/31/2012 <br /> Date: 03/08/2010 Contractor: Fisch Drilling <br /> Signature: a�& Title: Owner <br /> I Print Name: David Fisch <br /> I WORKER'S 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 <br /> provided for by section 3700 of the labor Code,for the performance of the work for which this <br /> permit Is issued. <br /> x I have and will maintain workers'compensation insurance,as required by Section 3700 of the <br /> Labor Code,for the performance of the work for which this permit is issued. My workers' <br /> compensation insurance carrier and policy numbers are: <br /> Carrier State Comp Ins Policy Number: 010825-09 <br /> 1 certify that in the performance of the work for which this permit is issued, I shall not employ any <br /> person in any manner so as to become subject to the workers'compensation law of California, and <br /> agree that if I should become subject to workers'compensation provisions of Section 3700 of the <br /> Labor Code, I shall forthwith comply with those provisions. <br /> Exp.Date:8/2090 Signature: <br /> Print Name: David Fisch <br /> WARNING:FAILURE To SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT AN EMPLOYER TO <br /> CRIIIIIIrAL PENALTIES AND CML FINES UP TO$100,000,IN ADDITION TO THE COST OF COMPENSATION,INTEREST, <br /> ATTORNEY'S FEES,AND DAMAGES AS PROVIDED FOR W SECTION 3706 OF THE LABOR CODE. <br /> AUTHORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> 1, (signature of C-6T licensed authorized representative), <br /> hereby authorize tpdnt name) John P. Lane, Lee&Pierce, Inc. ,to <br /> sign this San Joaquin county Well Permit Application on my behalf. i understand this authorization is valid <br /> for one year and Is limited to the work plan dated on the front page of this application. <br /> er29+o2M <br /> Ellh 2P-01 1 elulP7 WELL PMW APP <br /> I <br />