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APP -_::'005 14: 1E FPF_1[-1:ENPF'OE .�tt ;=itiL�. F1 T'is 19254Er,010 F.E <br /> U412.(/200n 14:nJ C.L HY I I '1LJUF Mi.Jae viae <br /> San Joaquin County Environmental Health Department Unit IV Well Permit Application Supplement <br /> JOB ADDRESS: 2 5- /��..vL Tit 'n PERMIT SR#: DDS�� 1-Y <br /> LICENSED CONTRACTORS DECLARATIONL( Cdr <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#: �7'7 l o o`7 Expiration Date; O 4&0 jy_o <br /> Date: q /7--7/2,005' Contractor. L Npr0 6 CN L,i rC A 6N I-AL— 17,1v bii✓lam' <br /> Signature: /)%- Title.•_ lfJl. Nt✓ <br /> Printed name: .!J e,i;u i S 07 T <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm under pertalty of penury one of the following deciarat3ons: (CHECK ONS) <br /> _ I have and wfll maintain a certificate of consatt to self-Insure for workers'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 /> I have and wfll maintain workers'coffoensatlon Insurance, as required by Section 3700 of the Labra Code, <br /> for the park mance of the work for which this permit is Issued. My workers' compensation insurance <br /> carrier and policy numbers are: <br /> Carrier: 5fa4C. Conlf�eN5o.+1 oN 7aswA-C-- Poncy Nurnbar.,7/3 7 3 & 3 <br /> FuaD <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 Califomia, and agree that if I <br /> should become subject to the workers'compensation provisions of Section 3700 of the Labor Code,l shall <br /> forthwith comply with those provisions. <br /> Expiration Date:J D -a1'05- Signature: <br /> Printed Name: LI)CN,v!`S 0-17- <br /> WARNING: <br /> "TWARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT <br /> AN EMPLOYER TO CRIMINA..PENALTIES AND CML FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> ($100,000.),114 AJ30171ON TO THE COST OF COMPENSATION.INTEREST,ATTORNEY'S FEES,AND DAMAGES AS <br /> PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. <br /> AUTHORIZATION FOR HER THAN C-57 SIGNING PERMIT APPLICATION <br /> J <br /> 1, ,&"',V/ L/LL (signature otc-57 licensed authortzedreptwuntaMm), <br /> hereby authtiriz+e(print name}to sign this San Joaquin County Well Permit Application on my behalf. I understand this authorisation Is valid for <br /> one(1)your and Is limited to the woric plan dated on the front page of this rappllcatfon, <br /> 8.29.02!Ill <br />