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01 / 04 / 10 09 : 50AN All Nel ' - 4bandonment 530 . 644 . 1439 p . 03 (�r� <br /> San Joaquin County Environmental Health Department Unit IV Well Permit Application Supplement <br /> JOB ADDRESS : I u l " (� o I-u � � PERMIT SR#: D bl� 0000 <br /> LICENSED CONTRACTORS DECLARATION ( LCD) <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 /> p <br /> License ff: R4A C)+ �(��L Exp�ira�tiycc Date: 110� �� � � � - <br /> Date: t � ( 3� 7 ' O ' I Contractor: _ vJC';�� I 6 ba CUM. -Li-ki-1I `-- <br /> . r _ Title: t re J X(J Q <br /> Signature: --' �'"�� r`^" y �1 ' n — <br /> Printed name: <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 insuran :e, as required by Section 3700 of the Labor Code, <br /> for the performance of the work for which this permit is i 3sued . My workers' compensation insurance <br /> carrier and policy� � }{�number}s-are: �J r <br /> Carrier: t - L U ` -t Policy Number: O ) 1OU N Oci <br /> I certify that in the performance of the work for which th s 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 p ovisions of Section 3700 of the Labor Code, I shall <br /> forthwith comply with those provisions, a. <br /> �� <br /> Expiration Date: 12 Signature <br /> r g� <br /> Printed Name: <br /> WARNING: FAILURE TO SECURE WORKERS' COMPENSATICiN COVERAGE IS UNLAWFUL, AND SHALL SUBJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES I IP TO ONE HUNDRED THOUSAND DOLLARS <br /> ($1003PROVIDED ORI <br /> , IN DIN SECTION THE COST <br /> OFTHE OFLABOR CODE, INTEREST, ATTORNEY'S FEES, AND DAMAGES AS <br /> AUTHORIZATION FOR QTHER THAN C-' i7 SIGNING PERMIT APPLICATION <br /> ;..� <br /> 1 -- s-; -''r°" w�lc• '" '=`""'"'"`- _(signature ofC-57 licensed authorized representative), <br /> hereby authorize (print name) Ally COlaVlta <br /> to sign this San Joaquin County Well Permit Application on n 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 /> 8-29.02 / MI - <br /> EHE 29-02-001 <br /> 6122/04 <br />