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2Q08-K-10 15:52 WDC RICHMOD, CA 1 >> 2094683433 P 3/3 <br /> San Joaquin County Environmental Health Oepariment Unit N Well Permit Appliea6on Supplement <br /> JOB ADDRESS: PERMIT SR#: <br /> LICENSED CONTRACTORS DECLARATION CD <br /> I hereby affirm that I am licensed under the provisions of Chapter 9(commencing with Section 7000)of Divislon <br /> 3 of the i3usiness and Professions Code and my license is in fun force and effect. <br /> Licence m: -es 5 3 2 , Expiration Date:„6 30 O <br /> Date: Contractor: <br /> Signature;_4 _..._„ti_. This t 1' OJtS” <br /> Printednarm:-6NR1S T�TUAiI <br /> WORKERS,COMPENSATION DECLARATION <br /> 1 hereby affirm under penalty of perjury one or the following declarations: (CHECK ONE) <br /> I have and will maintain a eedificate of consent to seff4risure for workers'compensation,as provided for <br /> �( by Section 3700 of ft tabor Code,for the performance of the Work for which this permit is issued. <br /> L 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: `':Sf> th, 11L'e P.1nC. POI1Cy Number:..WG 9Ot.[•'y fj 6&�J/ <br /> I certify that in the performance of the work for which this permit is issued,1 shall not employ any person in <br /> so a to become subject to the workers'compensation laws of California,and agree iha[if 1 <br /> should become to to the workers Compenaa n vis a. <br /> forthwith comply with those provisions. <br /> Expiration Date: d4-101102Signature: <br /> Printed Name:_ /RIS r A- 7Vr <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 /> AUTHORIZATION FOR p7TfER THAN C-57 SIGNING PERMIT APPLICATION <br /> I, Chris 'I'atuttl ��-� (signature ofC47'licensed authorized representative), <br /> hereby authorize(print namel Jeff Summers <br /> W sign"San Joaquin County Well Permit Application on my behalf I understand 1116 authorization is valid for <br /> I one(1)year and Is limited to the work plan dated on the front page of this application. <br /> e-29-021 MI t <br /> i:'F7A^Sf13.001 <br /> Cv37A4 <br /> 50 39'id 9E1 69KI'V6SZ6 4 <br /> T!y't 690ZlTE/£0 <br />