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04/27/2005 12:24 CLRYTOF ?OUP = 3130302 N0.310 G)02 <br /> • fl <br /> San Joaquin County Environmental Health Department Unit IV Well Permit Application Supplement <br /> .l08 ADDRESS: 2-� ��' ;? -�, �a�,�°j.�z;� <br /> 'sem PERMIT SR#: <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> I hereby affirm that I am licensed under the provisions of Chapter 9 (commencing with Section 7000) of Division <br /> 3 of the <br /> 13usrness and professions Code and my Ilcense Is in full force and effect. <br /> Llcense 97 `T �' Expiration Date: <br /> Date: Z7 Ccntractor: 71 ee -P_ f T! 4 4 ! <br /> Signature: l /Jim Tltie: ' ick ir/►gea. <br /> or <br /> Printed name: lr G! <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm under penarty of perjury one of the following declarations. (CHECK ONE) <br /> I have and will maintain a certificate of consent to self-insure forwarkers'.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 <br /> have and will maintain workers'compensation Insurance, as required by Section 3700 of the 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 /> Carder: ce�r�GQ+�� Pollcy Number: 0862 Y Q 2�� <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 Callfomia, and agree that if I <br /> should become subject to the workers' compensaticn provlslons of Section 37CO of the Labor Code, I shall <br /> forthwith comply wllth those provisions, <br /> Expiration Rats: ! l0 Signature: <br /> Printed Name: <br /> WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> (5200,000,),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 /> AUTHORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION ON <br /> 11 =L! Y!"rfs�e� (signature ofC-57 Ilcen2sed authorized mpresentatIve), <br /> hereby authorize(print name) <br /> i <br /> to ai®n this San Joaquin County Well Permit Application on my behalf. I understand this authorization Is valid for <br /> i <br /> rine (t)year and Is limited to tha work plan dated an the front page of this applicatlon. <br /> 8-29-02 r MI <br /> Fen, <br /> I 'dZOEOETESZ6 �UtIIT. JQ 22a.J9 d9S = 10 SO LZ -idd <br /> 17.02 2-T2cE <br />