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d <br /> San Joaquin County Environmental Health Department Unit IV Well Permit Application Supplemental <br /> JOB ADDRESS : PERMIT SR # <br /> LICENSED CONTRACTORS DECLARATION ( LCD ) <br /> I hereby affirm that I am licensed under the provisions of Chapter 9 (commencing with Section 7000) of <br /> Division 3 of the Business and Professions Code and my license is in full force and effect. <br /> i <br /> License #: C - 57 license 466270 Exp Date: 11 / 30 / 2010 <br /> Date: September / 27 , 2010 Contractor: Taber Consultants <br /> - J <br /> Signature: " " " Title : Senior Geologist <br /> Print Name: Thomas E . Ballard <br /> WORKER'S 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 <br /> provided for by section 3700 of the labor Code, for the performance of the work for which this <br /> permit is issued . <br /> X I have and will maintain workers' compensation insurance, as required by Section 3700 of the <br /> Labor Code, for the performance of the work for which this permit is issued . My workers' <br /> compensation insurance carrier and policy numbers are: <br /> State Compensation <br /> Carrier: Insurance Fund Policy Number: 0804685 - 2010 <br /> I certify that in the performance of the work for which this permit is issued , I shall not employ any <br /> person in any manner so as to become subject to the workers' compensation law of California , and <br /> agree that if I should become subject to workers' compensation provisions of Section 3700 of the <br /> Labor Code , I shall forthwith comply with those provisions . <br /> Digiant <br /> l arMartin Wrih <br /> N M <br /> ber, <br /> Exp. Date : 05 - 01 - 2011 Signature : _ Z _ """""""°` 1beconsu1antscoin �05 <br /> Print Name : Thomas E . Ballard <br /> WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL SUBJECT AN EMPLOYER TO <br /> CRIMINAL PENALTIES AND CIVIL FINES UP TO $100,000, IN ADDITION TO THE COST OF COMPENSATION, INTEREST, <br /> ATTORNEY'S FEES, AND DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. <br /> AUTHORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> I , (signature of C-57 licensed authorized representative), <br /> hereby authorize (print name) s to <br /> sign this San Joaquin county Well Permit Application on my behalf. I understand this authorization is valid <br /> for one year and is limited to the work plan dated on the front page of this application. <br /> R129102/MI <br /> EHD 29-01 1115107 WELL PERMIT APP <br />