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70 4GRM APEX ENVIROTECH, INC. NQ. M e r.c <br /> San Joaquin County Environmental'Health Department Unit IV Weil Permit application SuppiAmentai <br /> JOBADDRESS: _F 5►_(1ai f� �-�' PERMIT SR# <br /> LICENSED CONTRACTORS DECLARATION (LCA) <br /> I hereby affirm that 1 am licensed under the provisions of Chapter 9 (commencing vAth Section 7000)of <br /> Division 3 of the Business and Professions Code and my license Is In full force and effect. <br /> License#: '902 3 54 Exp Date: 2 31 a <br /> Date: 4/1d,06 Contractor. A,5 Z t t•L !N�+ <br /> Signature: <br /> Title: Via-l PrreS l'de_,L,-± <br /> Print Name: D_t Q U)i Wl L&IGH <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 self4nsure 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' oompeneation insurance, as required by Section 3700 of tha <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 /> Carrier: ��T( -e d1. Policy Number. 71 ?21 5S53-7' Q� <br /> I certify that in the performance of the work for which this permit Is issued, l 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'colt) ,ation provisions of Section 3700 of the <br /> Labor Cade, I shall forthwith comply with those pro ions. <br /> Exp. Date: Signature- <br /> Print Name: ! <br /> WARNING.FAILURE TO SECURE WORi(ERV COMPENSATION COVERAM IS UNLAWFUL,AND SHALLsUs ircT AN EMPLOYER TO <br /> CRIMINAL PENALTIES AND C1VL FINES UP To$100,000,IN ADDITION TO THE COST OF COMPBp9ATION,INTEREST, <br /> ATTORNEY'S RUES.AND DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. <br /> �/____171-HVUZ�ATl iN R THER THAN C-57 SIGNING PERMIT APPLICATION <br /> I, (signature of C-57 licansad authorized representative), <br /> here authorhw(print name 1 ,to <br /> sign this San Joaquin county Wail Permit Application on my behalf. I understand this awhorization is valid <br /> for one year and Is limited to tho work plan dated on the front page of this application. <br /> VM/021M1 <br /> Eh0 zs-ot 1+l6A7 <br /> ' WELL PERMTr App <br />