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Rr'r:. 10.2000 7°4C-RM APEiG ENVIROTECH,INC. NO.7,17 P.2 <br /> San Joaquin County Environmental Health Department Unit IV Well permit Application Supplemental <br /> JOB ADDRESS: 54 S IF ; h, _ -CA PERMIT SR# <br /> LICENSED CONTRACTORS DECLAMATION (LLCM) <br /> 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 /> License#: S b 2 3 3 Exp Date: 12.31 . 09 <br /> Date: v Contractor: K S.1- 3>>?l L L l N <br /> Signature: Title: �l '0 I�sreS II(�ulL <br /> Print Name: DZ?ti W1 NCS <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 /> I have and will maintain workers' compensation insurance, as required by Section 3700 of the <br /> labor Code,for the perforrnance of the work for which this permit Is issued, My workers' <br /> compensation A insurance carrier and policy numbers are: <br /> Calrrfer: S(�-�-� f�LK.A Policy Number: "- -7` Q <br /> I certify that in the perFormance of the work for which this permit is issued, I Shap 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' r) s-' <br /> ation provisions of Section 3700 of the <br /> Labor Code, I shall forthwith comply with those prl <br /> I ( b 1?-Z <br /> Exp, Date. 1 Z � ( � Signature: <br /> Print Name: Dt Ii r! <br /> WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL.,AND SHALL Su6J6cT AN EMPLOYER TO <br /> CRIMINAL PENAI.TIEB AND CIVIL FINES UP To$100,000,IN ADDMON TO THE COST OF COMPENSATION,INTEREST, <br /> ATToRN6Y'S FEES,AND DAMAGES As PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, <br /> UTH IZATI 14 9THER THAN C-57 SIGNING PERMIT APPLICATION <br /> 1, (signature of C•57 licalmsed authorized representative), <br /> here authorize (print name t ,to <br /> sign this San Joaquin county Well Permit;Application on my behalf. 1 understand this authorization is valid <br /> for one year and Is limited to the work plat~datod on the front page of this application. <br /> EH0 2fr01 11/6/07 WELL PE RMIT APP <br />