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r PR/02/2610 15:25 2094697704 e <br /> &W DRILLING PAGE 02 <br /> 4 i <br /> .. ?lldv <br /> 'San Joaquin County Envkronmental"sofa►Department Unit IV Well Putt Apprcatia n Suppf i <br /> JOB ADDRESS. �00 �i PERM $R� � 0066666 <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> i herebY affirm that I am licensed under the provisions of Chapter 8(cornmoncing with Section 700U)of <br /> Division 3 of the Business and Profiessiorts Code and MY license is in full force and <br /> License qa o cl 0 E Date: 2 0 £�0 9 <br /> Date: C Conbwtor- Yt } <br /> Signature: Title: <br /> Print Name. `( <br /> WORKER13 GOMPEN9A M DECiARATIOPt <br /> I hereby affirm under penalty of patrjury one of the folkwAng declamfions: (check one) <br /> I have and will maintain a certificate of consent to self-inwre frw workers'cornpensation,as <br /> Praviaed far by wton 3700 of the labor Code,far the i erbrn tante of the work <br /> Permit is issufar which this <br /> eet. <br /> I have and will maintain workers'8ncompensation insurance, as required by SoCtion 37 of <br /> Labor Code, fbr the periomtance Of the work for which this permit is issued. .My w1m the <br /> compen!saWn insurance ramie d policy numbers arse: 0 Coll <br /> Carrier: Polley Number. r1l)—u4c, <br /> I certify that in the peftfllrance of the work for which this permft is issued, f shall riot errvoy any <br /> Person in arry manner so as to become subject to the workers compenation law Of California,and <br /> agree that if 1 should become subject to workers' aamperisation provisions of Section 3700 of the <br /> Labor shaft fi�rthwi h ConVly with those proY <br /> Exp.Date- � Sigemtutre: <br /> PrintName: Rbbe_-,r-� vk-kk4. <br /> WARMUdG.FAILURE To SECU:a MpMEW MAT"COVERAM�s <br /> �4"AL PMALTIES ANO CMIL FUG S UP To$1MOM IN ADDeTM T��7 SHALL <br /> SIJB,et?t�T wet (pY TD <br /> ATTQRPRY'S Fes,AND DAxEAan A2 PRcmmm Fort m SECTUM wM OF THE LAW*COM TKM,atlEtm. <br /> O R OTHER THAN C-57 SIGNING PERMIT APPUCATION <br /> {signer of fi a p aloe MPvo <br /> hereby taorlze(print name) ?+ <br /> n this Barr 't0 <br /> s <br /> JckR"in county Waft p►nnuc�en on nv . I und�tand this XUAKxtumon is valid <br /> for one year and is iimf 8d tta the warn plash dat®d on ale tweet fame ofthis appllt„a*M. <br /> WW82M <br /> (St1�2li.Dt titrS,p7 . <br /> WK&MW AFP <br />