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03 / 01 / 2007 12 : 47 9166:. 11 CASCADEDRILLII,. PAGE 02/ grU <br /> ICV . t, 01 /. VV1 1 U k JMY1 nu Vall Ltu VCVLIIV I I VIIIIICII Lai Ir0. 7lut 1' . L <br /> I <br />•! San Joaquin County Environmental Health Department Unit IV Well Permit Application stipplemant <br /> JOB ADDRESS: : II. PERMIT SR#: CoAI SB �- <br /> LICENSED CONTRACTORS DECLARATION (LCI]) <br /> I hereby affirm that I am licensed under the provisions of Chapter s (commencing with Section 7000) of Division <br /> 3 of the Business and Profassien6 9010 and my Ilcense is In full force and effect. <br /> Llcens® ?y 510 ^ ExpirMlan Date: 1 � 31 W to 3 <br /> Date; ^ r iS 0 Contractor; I ) <br /> Signature; 41 Title: © p ' A_ <br /> Printed named <br /> WORKERS' 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 proWded for <br /> by Section 3700 of the Labor Code, for the performance of the work for which this permit is issued, <br /> I have and will malntaln 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' compenaetlon insuranoe <br /> carrier and piney numbers are; <br /> Carrler; � a5 �� 1�IGtdla � y O (dil� �S30`� I <br /> Policy Number. � <br /> I certify that In the performance of the work for which this permit Is Issued, I shall not employ any parson in <br /> any manner so as to become subject to the workers' compensation laws of California, and agree that if I <br /> should become subject to the workers' compensation provisions of Section 3700 of the Labor Code, I shell <br /> forthwith comply with those provisions; <br /> Expiratlod Date: ^^ I O1 Signature; r <br /> Printed Name: 6r 'neS to } 1e1 � Q <br /> WARNING: PAILURE TO SECURE WORKERS' COMPENSATION COVERAGE 18 UNLAWFUL, AND $HALL 0UWRCT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> (f14Q1000.11 IN ADDITION TO THE COST Or COMPENSATION; INTEREST, ATTORNEY'S FEE$, AND DAMAGED$ AS <br /> PROVIDED FOR IN SECTION 3700 OF THE LABOR CODE. <br /> AUTHORIZATION FOR OTHER THAN C47 SIGNING PERMIT APPLICATION <br /> I' tafgratum orc-67 licensed 114thorzed Tepresentativo), <br /> hembyauthorize (primTwin e) Becky Lee <br /> . to sign this San Joaquin County Well Permit Applipa40h on my behalf. I ondoratand this authorization is valid for <br /> ane (f) year and Is Ilmned to the wank pian dated on tho front page of this appnoatlan, <br /> 0^2002 / MI <br /> END 2942461 <br /> 6Y6�1W <br />