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FPOM :ResonantSoniclnternational FAX NO. :5306682429 •Jul. 12 2005 04:06PM P3 <br /> San Joaquin County Environmental Health Department Unit IV Well Permit Application Supplement <br /> JOB ADDRESS: 0 p O2 )J p,I illi PERMIT SR#: <br /> LICENSED 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#: gDZ 5 3 Expiration Date /2�3/�� <br /> Date: 7 Coontractor. <br /> Signature: <br /> Title:—Z-2=1-11-4-rt <br /> Printed name: Rl t �— <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 provided 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 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: 54.4— Policy Number: i/aL S C S <br /> I certify that in the performance of the work for which 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 become subject to the workers' compensation provisions of Section 3700 of the Labor Code, I shall <br /> forthwith comply with those provisions. <br /> Date: Signature: <br /> 1�, <br /> Printed Nam .' <br /> WARNING: FAILURE TO SECURE WORKERS' COMPENSATIO COVERAGE IS UNLAWFUL,AND SHALL SUBJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP To ONE HUNDRED THOUSAND DOLLARS <br /> PROVIDED SECTION To 77 BOF THE LABOR DATION, INTEREST,ATTORNEY'S FEES,AND DAMAGES AS <br /> FOR <br /> AUTHORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> (signature ofC-57 licensed authorized representative), <br /> hereby authorize(print <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 /> 9-29.02 l MI - ..� — <br />