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01/25/2005 10:02 9166385"11 CASCADEDPILLING PAGE 02/02 <br /> } C�11 Gam!LCi rJ7 G�:7L 7J.00o. tr1 a��.urc r"H.�t GL!G[ <br /> �v sdI� .✓ r �� P���� 2�8"� S <br /> San Joliqul» County EnVirOhmentaf Health Department Unit Iv Well Permit Application Supplement <br /> JOS ADDRESS- <br /> PERMIT SR#: x-305 <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> hereby affirm that I am Iicinnsed under the-,provisions of Chapter 9 (commencing with Section 7000)of Division <br /> 3 of the Business and Profeasions Cedar and rriy poemaA is in full force and effao <br /> license#; ,717S-1Q Pxplration bate. / C1 <br /> Date: <br /> Cont ctor. <br /> Signature: <br /> Title: <br /> Printed name: <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the following declarations: (CHECK ONE) <br /> f have and 37 0 Of <br /> a e9rtifi dpi,ate of consent to relNnatlre for workers'oompansation,as providgb fflP <br /> by Section 3700 of the✓ abor Code,far the performance of the work for which this permit is issued, <br /> l have and will maint0in workors'compensation insurance,as required by Section 3700 of the labor Code <br /> for thea performance Of the work for which this permit is lreued. Arty workers'comvensation insurance <br /> carrier and policy numbers are: <br /> Carrier: is <br /> � DXlmv Policy Number: Q ��3 <br /> i oertlfy that in the performance of thO work for which this permit is Issued,I shall riot SmPloy an <br /> son 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 visions. compensation provisions of Section 3700 of the Labor Code, f snail <br /> forthwith camplywith apse provisions. <br /> Expiration Date: Q <br /> Signature. <br /> Printad Name: <br /> WARNING.,FAILURE To SECURE WORKERS'COMPENS ITi4 4N COQ <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CIViL PINES Ufa TO ONEAHUNDREDLAVVFUL,AND SHALL SU8.�ECT <br /> PROM <br /> ($100,000.),IN ADDITION O 771E COST OF COMPENSATION,INTEREST,ATTORNE SFEESNAN DOLLARS MAGES AS <br /> PROVIDED FOR IN SECTION 3706 OF THE <br /> LABOR COOS, <br /> A THORIZq , iW !: R yFa TWAN C�57 SiGNINC PERMIT APPLICATION <br /> (slgnature at'C-57 licensed authorr±ed reprOsentativ,e), <br /> hemby authorite(print name) <br /> f <br /> in County well permit Application on my behalf. I understand this authorization <br /> td sign this San Jea�qut9 valid for , <br /> dno(1)year and;15 Ilmited to the work plan dated on thin front page of this eppllention, <br /> 8-29-021 MI <br /> RpD 20- 2.%Io i <br /> V22)04 <br />