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RF OM :Resonant5onicInternational FAX N0. :5306682429 May. 05 2004 06:08AM P2 <br /> artment Unit IV Well Permit Application Supplement <br /> San Joaquin County Environmental Health Dep <br /> JOB ADDRESS: 1313 0 5 C, � .— 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#; <br /> r � >:� ! Expirallon Date: ),2 •--5f ���~ <br /> Contractor: <br /> Date: — ' <br /> Signature: <br /> a \C'� ,��..�?_.�'��� Title: <br /> `� N t " <br /> Printed name: 1221L2 ` <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 aeif-Insure for workers' compensation,as provided for <br /> by SHotion 3700 of the Labor Code,for the performance of the work for which this permit is Issued. <br /> ce, as <br /> equired by <br /> n'3700 of <br /> he <br /> vfor the perfor�manclell tof the work for which this ain workers' ope mit is issued.ssued r My workers'compensation insurance <br /> nsuranceCode, <br /> carrier and policy numbers are: <br /> lC_ - l j- <br /> l t: I U:(�r _ Policy Number: n �, > <br /> Carrier: — <br /> I certify that in the performance of the work for which this permit is issued, l 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, r-- �I " <br /> Expiration pate: 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 FINIS UP TO ONE HUNDRED THOUSAND DOLLARS <br /> P$100,000.),IN ADITION TO THE COST ROVIDEp ADN SECTION 3708 OF THE LABO <br /> R NS TON,INTEREST,ATTORNEY'S FEES,AND DAMAGES AS <br /> E. <br /> AUTHORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> (signatureofC-57 licensed authorized representative), <br /> hereby authorize(print narne) �� <br /> to sign thio San Joaquin County Well Permit Application on my behalf. 1 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 /> EHD 29.01.001 <br />