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Q Oct . 20, 2005 10 : 54AM '-{vanced Geo Environmental No . 2593 P . 2 <br /> tl <br /> San Joaquin County Environmental Healtth� Department Unit IV Well PemitApplication Supplement <br /> JOB ADDRESS : F'�COS PERMIT SR#: i <br /> LICENSER CONTRACTORS DECLARATION LCD <br /> I 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 and effect, <br /> License 8: Expiration Date: b 13 o / O 7 <br /> Date: 3 o f yv/ bJ Contractor. M t fG Ka f ( 67 P( i T7li :�, fJV . Ga 2(¢ <br /> Signature : — -- " Title: V� £� <br /> Printed name; Fi-ftk51*VJ(Y 6f<E. I.- <br /> WORKERS' COMPENSATION DECLARATION <br /> 1 hereby affirm under penalty of perjury oneof 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 /> carrier and policy numbers are: <br /> Carrier: VI P 0f tA- GJ- Policy Number. dby' - b 1 SSE <br /> I certify that In the performance of the work forwhich this permit is issued, I shall not employ any person in <br /> any manner so as to become subject to the workers' compensation laws of California, and agree that if I <br /> should became subject to the workers' compensation provisions of Section 3700 of the Labor Code, I shall <br /> forthwith comply with those provisions. <br /> Expiration Date: t OG Signature: <br /> Printed Name: at P-aXJD OAV i (1^ 614;�-07d�CC <br /> WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL SUBJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND COLLARS <br /> (ll100,00DJ, IN ADDITION TO THE COST OF COMPENSATION, INTEREST, ATTORNEY'S FEES, AND DAMAGES AS <br /> PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, <br /> AUTHORIZATION FOR 0774ER THAN C47 SIGNING PERMIT APPLICATION <br /> I, i+A P� tl7 O�- OAV i 0 U/W P "lU�� (s(gnature olC-67 licensed authorized representative), <br /> i✓ <br /> hereby authorize (print name) PhIv \LP4 13A C r <br /> to sign this San Joaquin County Well Permit Application on my behalf. I understand this authorization Is valid for <br /> one (1 ) year and is limited to the work plan dated on the front page of this application. <br /> 8-29-021 MI <br /> EtM 19.01-001 <br /> 621/Dt <br />