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08/08/2007 10:03 FAX 12002/002 <br /> San Joaquin County Environmental Health Department Unit IV Well Permit Application Supplement <br /> JOB ADDRESS: I L1-5 0 VV- Ir"24'�- PERMIT SR#: 0C>:( 5'-Lfir <br /> LICENSED CONTRACTORS DECLARATIONLi CD) <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#: 4&-7 25- 1 Expiration Date: 2— U ! <br /> Date: ( � l J Contractor: <br /> Signature: r� � �Q_Title: �,p��-,�1 jffiL]J Nos {ALJ h1�i ('t¢1( Y_ <br /> 1- <br /> Printed name: &V l�� Ci �I Z I aI, r - <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 /> -/ l 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: 1�-,' I ,{ <br /> Carrier:L4G1CI6Tt Ir1Jwt"Gkn(-,— araPolicy, , Number: yJ /c I (`i�� �, chi <br /> 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 /> Expiration Date: Signature: nv(�1--�- <br /> Printed Name: Y A U f <br /> WARNING:FAILURL TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> ($100,000.),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 OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> I, (signature ofC-S7 licensed authorized representative), <br /> hereby authorize(print name) <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 /> 8-29-02/MI <br /> E14 D 29-02-001 <br /> 6/22/04 <br />