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06/06/2007 09: 13 5102370" PRECISION SAMPLI' PAGE 02/02 <br /> n <br /> San Joaquin County Environmental Health A�artment unit IV Well Permit Application Supplement <br /> JOB ADDRESS: /J• 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#: (034Q 3 __ _ _ Expiration Date: 1 31 L)00 <br /> Date: © --Contractor. ?rec:�1 cnn 7a w,a�• ►- 1 <br /> Sighatur Title: A— IAL', <br /> Printed name: <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the following declarations: (CHECK ONE) <br /> _1 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 /> 1 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: �t p <br /> Carrier. Com` M(JJ Policy Number:VjL1 1.b -a3 I�c� <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 /> Expiration Date:(0 —�O 10b Signature: <br /> Printed Name: <br /> WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONI_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 /> AUTHO ATION FOR OTHER THAN C-$7 SIGNING PERMIT APPLICATION <br /> (signature ofC-67licensed authorized representative), <br /> hereby authorize(print name) Alex / Iat-t-�C(� , <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 /> E•HD 29.02.001 <br /> f/22/04 <br />