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2008-041-10 15:52 WDC RICHMOND, CA 1 >> 2094683433 P 2/3 <br /> San Joaquin County EnWronmental Hearth Department Unit IV Well PertnitAppilcation Supplement <br /> JOB ADDRESS: PERMIT SR#; <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> hereby affirm that I am licensed under the provisions of chapterg(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#: a a 33:21 t> Expiration Date: r"13a1D r <br /> Date:a4 ,92/'e78 contractor <br /> , r=te el oprr o s <br /> Signature: "✓/_t./-�--�"'-"tet_ l�,1 � — Title: <br /> Printed name' (i!T e.9 A-7VA4 V <br /> WORKERS'COMPENSA'noN DECLARATION <br /> I hereby affirm under penalty of perjury one of the following declarations: (CHECK ONE) <br /> I have and will maintain a cartificate of consent to selfbinsure 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 Cade, <br /> for the performance of the work for which this permit is issued. My workers'compensstion insurance <br /> carrier and policy numbers are:d <br /> earrier.,r�%r�°J C", 7FZ'Cky I17r. Policy Number. We 9e+7 S&glv <br /> I canify that in the performance of the work for which tMs permit is issued, 1 shak not employ any person in <br /> any manner so as to become subject to the workers'compensetlon 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 cbrnply With those provisions <br /> s•. <br /> Expiration Date: ?A/01 102 Signature: -z <br /> Printed Name: CJ R!S TA `71.)A4 <br /> WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CAM.PINES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> (5100,000.),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 /> AUTHORIZATION FOR OTHER THAN C-67 SIGNING PERMIT APPLICATION <br /> Chris Tatum ; '' (signature oIC47 licensed authorhedrepresentadyel, <br /> hereby Ruthorlxe(Print nems, Jeff Summers <br /> to sign this San Joaquin County Well Permit Appileadon on my behalf, I understand this authorization Is valid for <br /> one(1)year and Is limited to The*vrk plan dated on&a front page of this application. <br /> &29-021 M1 <br /> ERD.29.02-001 <br /> da'03 <br /> ca 3'1Cd 951 658SDb65Z6 LT:bt 8902/TE/E9 <br />