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09/02/2004 11:29 2094611 AGE STUCKTON N./ PAGE 02/02 <br /> Son Joaquin County Environmental Health Department Unit IV Well Permit Application Supplement <br /> JOE:ADDRESS: PERMIT SRN: <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> I hemby affirm that I am licensed under the provisions of Chapter 9(=Mrnefting with Section 7000)of Division <br /> 3 of tie Business and Professions Code and my license Is in full force and o feact. <br /> Lican ae#: �Rp 0:7._ Expiration Date, <br /> Dal:. Contractor. <br /> Sign,lure: <br /> IVTill <br /> 7� �__� <br /> PrintiA narnee:� L <br /> W RKERS'COMPENSATION DECLARATION <br /> I mere�y 21T►m under penaly of perjury one of the following declarations- (CHECK ONE) <br /> 1 I lave and will maintain a mr ificate of consent to self-insure for workers'compensation, as provided for <br /> bl'Section 3700 of the Labor Code,for the performance of the work for which this permit is issued. <br /> koI cave and will maintain workers'compensaWn Insurance, as reel iread by Section 3700 of the Labor Code, <br /> -the performance of the work for which this permit is issued. My workers'compensation insurance <br /> rrier and policy numbers are., <br /> Carrier: =+-+ Policy Nllmber: bt to -Z, <br /> 1 cartlfy that in the performance of the work for which"s permit jr.issued, I shall not employ any person in <br /> any manner so as to become subject to ft workers'compensation laws of California,and agree that KI <br /> sh.iufd be:corrle subject to the workers'Compensation p ons of Section 3700 of the Labor Code,J shall <br /> forthwith comply with t <br /> hose provisions, t <br /> Explra:ion date: �f._.[ J Signature: Y <br /> �- Printed Name: <br /> wARNrI It-:FArLURE TO SECURE WORKERS'COMPF-NSA710M CoVr;RAGE IS UNLAWFUL,AND SHALL SUBJECT <br /> AN EMULOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED TMDUSAND DOLLARS <br /> ($100,00.),IN ADDITION TO THE COST OF COMPE1'M ION,INTEREST,ATTORNEY's FEES,AND DAMAGES As <br /> PROVIC ED FOR IN SECTION:1706 OF TME LABOR CODE. <br /> AUTHORIZATION FOR OTHER 7'HA.N C-57 SIGNING PERMIT APPLICATION <br /> i <br /> ' (slgnaturre OIC-67 licensed authorized r.prosentollve), <br /> hereby I utharize(print name)_ <br /> to alga t'is San J"WIn County Well Permit Application an my behalf, I underst n this authorizatlon is valld for <br /> ore(1)y ear and is Ilmited to V a wont plan doted on the front page of Ihis application. <br /> rt-,29-p2 IMI <br /> EHD 29M24Iq <br /> 677!01 <br /> Z 'd S T LS61 6906 uap i eN Rjew dEZ :;30 fr0 z0 claS <br />