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06/13/2007 FVED 16:55 FAX 2093699608 Z002 <br /> San Joaquin County Environmental Health Department Unit IV Well PefmftApptication Supplement <br /> JOB ADDRESS: PERMIT SR#: <br /> LICENSED CONTRACTORS DECLARATIONL( CDl <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#. _7.20 910`1 Expiration <br /> Date-- <br /> 4,,,/ �QB <br /> Date: Contractor. V-1 I' �� <br /> Signature: Title: -� <br /> Printed name: K <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 self4nsure forworkers' 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 /> _L,,l have and will maintain workers'compensation insurance, as required by Section 3700 ofthe 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 /> Carrler:iltb l�_ Policy Number: 17 5 9 A,064 <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 1 <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: Signature: <br /> Printed Name: <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 /> I, AUTHORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> (signature ofC-57 licensed authoriz d representative), <br /> hereby authorize(print name) o t I Ar-o-\-S- rc? 1G , <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 /> 8-2"21 Mt <br /> lillD 29-02-001 <br /> 6/22/Oq <br />