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MAY-17-2004 13:4e FROM:ENPROB 5305892230 T0:12099480621 P,2 <br /> San Joaquin County Environmerdafealth Departmen Unit IV Well Permit Application Supplement <br /> JOB ADDRESS, TT Z f e. -( PERMIT SR#: <br /> LICENSED CONTRACTORS DECLARATION LCD <br /> 1 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 <br /> nand effe <br /> Dql O bLicense Ex <br /> Date: Con actor- 12d g <br /> Signature: / Title: ��li^wy' /2 <br /> Printed name: _/ /o., �` <br /> i <br /> WORKERS' COMPENSATION DECLARATION <br /> 1 hereby affirm under penalty Of perjury ane 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 /> 1 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 /> carver and policy numbers are: <br /> Carrier: M fiAJ OA Policy Number 0130713L34- 7a , <br /> I certify that In the performance of the work for which this permit Is Issued, I shall not employ any person in <br /> any manner so as to became subject to the workers'corn ensation laws of California, and agree that if I <br /> should become subject to the workers'compensation cions of Sedfon 3700 of the Labor Code, I shall <br /> forthwith comply with tho a provisions. <br /> Expiration Date:/a// ,O Signature: 910 <br /> Printed Name: <br /> WARNING: FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUnJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINE$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 CODC. <br /> %�AUTHORIIZATTION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> t'--1�[1_AL�L_L4t2n n Isigmdure ofC67 licensed outhod=d representative), <br /> hereby authtza(print name) )w1 Lr/TF,t <br /> to sign this San Joaquin County Well Pennit) ppllcatlon on my behalf. I understand this authorization Is Valid for <br /> one(1)year and is 0mited to the weak plan dated on the f nt page of this application. <br /> 8-29.021 MI <br /> EHD 29-02-001 <br /> 9/30/2007 <br /> 05/17/2004 MON 14:49 [TX/RX NO 53741 0 002 <br />