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Sep 04 2003 15: 10 %)IRONER INC. -7.05687679 p. 2 San Joaquin County Environmental Health Department Unit IV Well Permit Application Supplement JOB ADDRESS:_ SLI I W. (Sxavil L I,,4'- f200A PERMIT SR#: TactT , CA- LICENSED CONTRACTORS DECLARATIONL( CD) I hereby affirm that 1 am licensed under the provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code and my license is in full force and effect. License#: -7(p `J 9 —A _1 Expiration Date: Date: I Li U Contractor. _ V t r1_0 VC�1 Signature' -L Int— Title: Printed name: fL.1� 1 31n , t-e WORKERS' COMPENSATION DECLARATION hereby affirm under penalty of perjury one of the following declarations: (CHECK ONE) I have and will maintain a certificate of consent to self-insure forworkers' compensation, as provided for by Section 3700 of the Labor Code, for the performance of the work for which this permit Is issued. i J have and will maintain workers' compensation insurance, as required by Section 3700 of the Labor Code, for the performance;of the work for which this permit is issued. My workers' compensation insurance carrier and policy numbers are: Carrier. 6-V-6lel VC ��-CR Policy Number: LL)C, 105 4S (P 1 certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to:become subject to the workers' compensation laws of California, and agree that if should become subject to the workers' compensation provisions of Section 3700 of the Labor Code, I shall forthwith comply with those provisions. Date: Signature: W Printed Name: I WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS ($100,000.), IN ADDITION TO THE COST OF COMPENSATION, INTEREST, ATTORNEY'S FEES, AND DAMAGES A5 PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. AUTHORIZATION FOR+ _OTHER THAN C-57 SIGNING PERMIT APPLICATION (signature ofCZ7 licensed authorized representative), hereby authorize(print name) 6-�Aovt ) to sign this San Joaquin County Well Permit Application on my behalf. I understand this authorization is valid for one (1)year and Is IImited to the work plan dated on the front page of this application. 8-29-02/ MI I