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San Joaquin County Environmental Health Department Unit IV Well Permit Application Supplement <br /> JOB ADDRESS: MILGEO AVENUE/WILMA AVENUE RIPON PERMIT SR#: <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> I hereby affirm that I am licensed under the provisions of Chapter 9(conn,.- icing with Section 7000)of Division <br /> 3 of the Business and Professions Code and my license is in full force and Cffect. <br /> License#: C57-680227 Expiration Date: NCV2MBER 2007 <br /> Date: Os NOVEMBER 2007 Contractor: ADVANCED GEOENVIRONMENT&W, INC <br /> Signature: Title: vic L�KESIDENT <br /> E. MARTY <br /> Printed name: ROBE - _ <br /> WORKERS' COMPENSATION DECLA,° aTION <br /> I hereby affirm under penalty of perjury one of the fallowing declarations: (:_HECK ONE) <br /> _I have and will maintain a certificate of consent to self-insure for won,, ;' ;ompensation, as provided for <br /> by Section 3700 of the Labor Code, for the performance of the work f(.. .-.hich this permit is issued. <br /> xx I have and will maintain workers' compensation insurance, as requirLi .,, Section 3700 of the Labor Code, <br /> for the performance of the work for which this permit is issued. My compensation insurance <br /> carrier and policy numbers are: <br /> STATE COMPENSATION <br /> INSURANCE FUND -774-2007 <br /> Carrier: Policy Number: <br /> I certify that in the performance of the work for which this permit is is.- Fhall not employ any person in <br /> any manner so as to become subject to the workers' compensation. ;.. California, and agree that if I <br /> should become subject to the workers' compensation provisions of F n 3700 of the Labor Code, I shall <br /> forthwith comply with those provisions. <br /> OI OCTOBER 2008 <br /> Expiration Date: Signature: <br /> Printed Name: ROBERT E. MARTY <br /> WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVEEA� AWFUL,AND SHALL SUBJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE ,. I HOUSAND DOLLARS <br /> ($100,000.),IN ADDITION TO THE COST OF COMPENSATION, INTEREST, Y'S FEES,AND DAMAGES AS <br /> PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. <br /> �THIZ ION FOR OTHER THAN C-57 SIGNING r�: RMIT APPLICATION <br /> 1, (signature ofr -ised authorized representative), <br /> hereby authorize(print name) ART UR DEIcxE <br /> to sign this San Joaquin County Well Permit Application on my behalf. this authorization is valid for <br /> one(1)year and is limited to the work plan dated on the front page of this a, _.on. <br /> 8-29-02 I M1 <br /> EHD 29-02-001 <br /> 6122!04 <br />