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San Joaquin County Environmental Health Department Unit IV Well Permit Ifcatlon Supplement <br /> JOB ADDRESS: //5'30 A/. CC/<11;r A/ice R�N c <br /> PERMIT SR#: 052' y <br /> 65411 72, W <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> sssssss <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 #: —I 10 0 "7 of Expiration Date: 01 b ( 01 oil <br /> Date: 104!3640w) Contractor: INODBtvAi° 0 T3R4LUrlmwa rhr/V rj&( <br /> Signature: r� DVT/�c✓ru �(Title: #�17F51a6�1 <br /> Printed name: (�g &jciRvr� 5� , I.fltw &ro� <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: ATE rwli) Policy Number: 002OZ39 � 2607 <br /> I certify that in the performance of the work forwhich 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: 200 8 Signature: Avi3z� <br /> Printed Name: C0Nc( AfQ' ty, WftDt.uPha-p <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.)0 IN ADDITION TO THE COST OF COMPENSATIONa INTEREST, ATTORNEY'S FEES, AND DAMAGES AS <br /> PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, <br /> AUTHORIZATION FOR OTIiER THAN C-57 SIGNING PERMIT APPLICATION <br /> is Z�c � ltf�(signature ofC-67licensed authorized representative), <br /> hereby authorize (print name)_ TODD /{?4Fjf/ale <br /> to sign this San Joaquin 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 /> 8.29.021 MI <br /> Run 29-02-001 <br /> 6/22/04 <br />