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02/06/2006 MON 08:50 FAX Z002/002 <br /> 02/02/20OG 10: 15 FAX Z 002/002 <br /> San Joaquin County Environmental Health Department Unit IV Well Permit Application Supplement <br /> JOB ADDRESS- 3�a _s �J PERMIT SR#-. �5 <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> hereby affirm that I am licensed under the provisions of Chapter 9(commencing with Section 7000) of Division <br /> 3 of the Busincss�and Professions Godc and my license is in full force and effect. /- <br /> License#S / <br /> SIf- .P ac10 Expiration Date-. 3� dCy <br /> ,_:�p Date: G Contractor (� / <br /> V�" '" �r I�f A/ <br /> Signature: Tltle:, �vdzoev✓ <br /> j Printed name: <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 self4risure 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 /> kI 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: /7 c� [� <br /> Carrier: ��e �IJIV Policy Number._ / 15 q�1 — aid 1 <br /> 1 certify that in the performance of the work for Wttich this permit is issued, I shall not employ any person in <br /> any manner so as to become subject to the workers'compensation lows of California, and agree that If I <br /> should become subject to the workers'compensation provisions of Section 3700 of the Labor Code, I shall <br /> forthwith comply with those provisions. <br /> Expiration Date: Signature: <br /> Printed Name: . e—j 04, ,,e <br /> WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE 15 UNLAWFUL,AND SHALL SUBJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CML FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> ($100,000.).IN ADDITION TO THE COST OF COMPENSATION,INTEREST,ATTORNEY'S FEES,AND DAMAGES A3 <br /> PROVIDED FOR IN SECTION 3106 OF THE LABOR CODE, <br /> THORIZ/ATION OR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> Ir 71 (signature�affC-67licensed auth4uri�<"e]d�r-presentative), <br /> hereby authorize(pent name) �rANf15 � } t L 0(� <br /> to sign this San Joaquin County Well Permit Application on my behalf. I undorefand 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 /> EI-29-02)MI <br /> EHD 29-02-6101 <br /> 6/22/04 <br /> 03/03/2006 FRI 09: 52 i;TX/RX No 66321 41002 <br />