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05/23/2009 16:16 2094697V&W DRILLING PAGE 02 <br /> Stanislaus County Environmental Health Department Well Permit Application Supplement <br /> JOB ADDRESS:_U4 2112 C'� `"_ PERMIT SR#: <br /> LICENSED CONTRACTORS DECLARATIONL( CD) <br /> 1 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#- 72 Q 9 U °I Expiration Date. I QU 9 <br /> Date:, \� � Contr or: L / <br /> Signature:��� / Titter <br /> Printed name: LL4 �'I c kpe;cy <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 self4risure for workers' compensation,as provided for <br /> by Section 3700 of the Labor Code, for the performance of the work for which this pearl[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'compensatlon Insurance <br /> carrier and policy numbers are, <br /> Carrier: 'j" L policy Number; <br /> I certify that in the performance of the work for which this permit is issued, 1 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 provis' s of Section 3700 of tge-C84gr Code, I shall <br /> forthwith comply WI those provisions_ <br /> Expiration Date: �r li Signature: 1 I( <br /> Printed Name: t 1� <br /> WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,\ D 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,ATTORNLY'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 ofC57 Ileenavd authorized representative), <br /> hevby authorize(print name) .V <br /> to sign this Stanlslaus 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 thio application. <br /> 8.29-M/MI <br /> E}D 29-02-001 <br /> 6/22/04 <br />