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01 / 04/ 10 09 : 50AM All Wel ' Abandonment 530 . 644 . 1439 - p . 03 <br />{ <br /> San Joaquin County Environmental Health Department Unit IV Well Permit Application Supplement <br /> JOB ADDRESS : I a ( l'' l PERMIT SR#: W L o,w <br /> LICENSED CONTRACTORS 0EGLARATION ( 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 /> �? jrt � r 7 /� <br /> License #: ( �� Exp'iraytiycn Date: ._I_�L� L—�LyJ� {/� � <br /> 11001 <br /> Date: �� � ��� � �� Contractor. t t � 1�16J M.ffif I.) <br /> Signature: -.. �s'-� '-"ter^`-.-y �-=...------ _ True: <br /> Printed name: 1 Y t 41 <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 /> x 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 ssued. My workers' compensation insurance <br /> carrier and <br /> l \ <br /> policy numbers <br /> -are: <br /> � � <br /> Carrier: oto . v i(j Policy Number; <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. _ <br /> Expiration Date: Si nature <br /> Printed Namec���j > <br /> WARNING: FAILURE TO SECURE WORKERS' COMPENSATICiN 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 /> AUTHORIZATIONFOR OZHERTHAN C ! i7 SIGNING PERMIT APPLICATION <br /> signature ofC-671icensed authorized representative), <br /> hereby authorize (print name) Ally Colavita <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 /> 8-29-021 MI <br /> EHD 24-02-001 <br /> 6122/04 <br />.I <br />