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02/26/2008 15:48 707374'"77 WOODWARD YARD PAGE 02/02 <br /> 0 <br /> 02/26/2008 12:24 5366005 STRATUS NO CAL`P, PAGE 01/01 <br /> San Joaquin County Environmental Health Deparanent Unit IV Well Permit Appl)Ctttion Supplement <br /> JOB ADDRESS: Mfb'6B u1 ty t tvy cl PERMIT SR#; <br /> LICENSED CONTRACTORS DECLARATIONL( CD) <br /> I hereby Wren that 1 am licensed under the provisions of Chapter 2(commencing with Section 7000)of Divislan <br /> 3 of the Business and Professions Coda and my license is in Nil force and effect. <br /> License#: 9 E*Iration Data:. CS-7 —31 "d�( <br /> Date: CM124,(f18 Contractor._ \40DWPd-D lbpkt w6 <br /> signature: ` � a. £ (�ovclr+>—rcn rI Title: <br /> Printed name: �+�irV(K E, I:tRTo9trA11s <br /> WORKERS,cOMPENSA i,ON DECLARATION <br /> I hereby affirm under penalty of perjury one of the following declarations: (CHECK ONE) <br /> _ t have and wit(maintain a certificate of Consent to se1f4ruture 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 /> „,r,1 have and Will Maintain workers'compensation insurance,as required by Section 3700 of the Labor Cade, <br /> for the performance of the work for which this permit is issued. My workers'compensation insurance <br /> Cartier and policy numbers are: <br /> Carrier: S Policy Number: 002.o232-2007 <br /> 1 certify that in the Performance of the work for which this permit is issued,l o <br /> any manner so at to become subject tD the workers'compensation lawn in <br /> s I Califon a,Slid agree that Shall not employ any person <br /> if 1 <br /> should become subject to the w01k613'compensation provisions of Section 3700 of the <br /> forthwith comply with those prrnNgions. Labor Code, I shall <br /> Expiration Date;J6 '200 11 Signature: <br /> Printed Name: GoA2r,V , L✓UUDlM1�fl <br /> WARNING:FAILURE TO SECURE WORKERS'COMP@NSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> (S10D,00o.),IN ADDITION TO THE COST OF COMPENSATION,INTEREST,ATTORNEYS FEES,AND DAMAGES AS <br /> PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. <br /> AUTHORIZATION FOR OTHER THAN CS7 SIGNING PERMIT APPLICATION <br /> I. w <br /> ��..—..(signafur0 ofCa711Cenaed authneized repn�erntfivej, <br /> hereby aufttorize fp M <br /> name. <br /> (I r n i S <br /> to sign this San Joaquin County Well Permit Application on my behalf. I undersand tats 2uatora4on Is Valid for <br /> one(t)ye4r and Is Iflnitsd to the Werk plan dated on the fmnt page of this application. <br /> g-Z8d2/Mt <br /> t EHD 29, b001 <br /> 6/22AU <br />