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02/a9/?au 11:14 2e97283@76 <br /> C1F'ERID INC • PEG- a2/02 <br /> San Joaquin County Environmental Health Oapartment Unit N Well Permit Application Supplement <br /> JOB ADDRESS: /rt ,' e r G �atPERMIT SR#;_� <br /> LICENSED CONTRACTORS DECLARATION LGD <br /> 1 hereby affirm that I em licensed under the provisions of Chapter 3(commendng with Section 70001,of Dlvls?on <br /> 3 of the Business and Professions Code and n'y license is In full force and effect/ <br /> license fr 70(7 S(�0' Expiration Date: <br /> Date: �-�}-o (� Contractor iF(i lb2Yi`iQU GiR(tFozivrq 3fNG <br /> Signature. r Q Title: DfZfC'21a2 ..� <br /> Printed name:. <br /> WORKERS'COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the following declarations: (CHECK ONE) <br /> _ I hexa end will rraintain a cerifiwe of consent to self-insure for workers'compens@Een,as provided for <br /> by Section 3700 of the Labor Code,for the performance of the work for which this permit Is Issued, <br /> have and will maintain workers'compensation insurance,as required by Section 3700 of t)a Labor Coos, <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. ��- -'^-�n Policy Number. / (66(093 -4v S-- <br /> 1 Cantly that In the performance of the work for which this permit is Issued. I shall not employ any person m <br /> any manner so as to become subject to the woft&compensation laws of Cefifomia,and agree that if I <br /> should become subject to the workers'compensation provisions of Section 3700 of i^ Labor Code,I shall <br /> forum M comply with thea@ previsions. <br /> Expiration Date Signahrce: <br /> Printed Name: <br /> WARNING:FAILURE TO SECURE WORKERS'COMPENfiATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES ANP CIVIL FINILS UP TO ONE MUNDRED'rHOUSANO DOLLARS <br /> (5100,000.).IN ADDITION TO TME COST OF COMPENSATION,INTEREST,ATTORNETH FEES,AND DAMA6'rS A8 <br /> PROVIDEp FOR 1N SECTION 3706 OF THE LABOR CODE <br /> AUTHO 1 ON OR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> l' (sign@tum OfC3711cana94 authorized I'aplesentativs), <br /> hereby authortm(printan rim) JrM 2t9ENL <br /> r <br /> to sign this San Joaquin COuny Well Permit Applloatlon en my behalf. I understand this author¢ation Is valid for <br /> One(1)year and In limited W the work plan dated on the front page of this application. <br /> 8.79.02/MI <br /> E M 29-02001 <br /> 52209 <br />