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'\ San Joaquin County Environmental Health Department Unit IV Well Permit Application Supplement <br /> l JOB ADDRESS:_aC905 SOA Mac A14itm '&A 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#: CO 3CP 3151— Expiration Date: 200(p <br /> Date: 200r2 Contractor. W15Gk&:340 1 �iD•MPt�11Jli 1061 <br /> T <br /> Signature: Title: _ r Kkke 1 pd� <br /> Printed name: <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 /> v I 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: <br /> Carrier: U%91-4 hAU'(UA6.,, Policy Number: b1.f5 <br /> 1 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: QIP—Signature: —� <br /> Printed Name: N 1� <br /> WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CML 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 /> AUT OR TION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> ol <br /> b (signature ofC-07 licensed authorized representative), <br /> hereby authorize(print name) GEDKMV,1% 60,QV�d. <br /> T <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 /> EHD 29-02.001 <br /> 6/22/04 <br />