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06/07/2005 08:55 5306628057 WDC EXPLORATION PACS 04 <br /> San Joaquin County Environmental Health Department Unit IV Well Permit Application Supplement <br /> JOB ADDRESS: 1 Z 68 Locke PERMIT SR#: <br /> LoDkeFoeaf CA <br /> LICENSED CONTRACTORS DECLARATION (LCDI <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#-,C--S7 4933 2(m Expiration Date:.. h/3 O/2'00(v <br /> Date:-W-0-71 S Contractor . loc +; -r I <br /> Signature: Title:.�� <br /> Printer name: e Yl 6 p C t <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 /> 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 arrnnUd policy numbers are: <br /> Carrier.,Ae4ee�h Policy Number: DOOM Llgp <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,01 o f -&b(+ Signature: <br /> Printed Name: 51 _ <br /> WARNING: FAILURE 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 3700 OF THE LABOR CODE. <br /> AUTHORIZATION FOR OTHE THAN C-57 SIGNING PERMIT APPLICATION <br /> 1• (signature ofC-67licensed 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 /> 6.29-02 r MI <br /> EHO 29-02.001 <br /> N22r04 <br />