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43119'2003 !0:45 2094583433 <br /> FIF'Tl-i FLaQkk rr-ram. �u <br /> San Joaquin County Environmental Health Department Unit IV Well Permit Application Supplement <br /> JOB ADDRESS: I 9501 A/ Nw - PERMIT SR#: <br /> LICENSED CONTRACTORS DECLARATIONL{ CD <br /> I hereby affirm that 4 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#; C,-Jr 7"it 6o ly _ Expiration Date: 41—10'�3 <br /> 3 Contractor-.�41( O. {r}r`10RrJ0N e t3 S SOS <br /> Title: <br /> pr �/LLtyt�-U" �1rcc¢or _Nur SErNC[J <br /> Signature' _.�_, �. <br /> Printed name: 'Zdlaer-r A. Nr CAo/SaM <br /> WORKERS' COMPENSATION DECLARATION <br /> 1 hereby affirm under penalty of perjury one of the following declarations: (CHECK ONE) <br /> I have and will maintain a certificate of consent 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 /> 1 have and will maintain workers'compensation insurance,as requlred 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 /> Carrier: S7t4t, Comp SNS. CuryD ^Policy Number: 123 776 -, 03 <br /> I certify that in the performance of the work for whivh 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 I <br /> should become subject to the workers'corn pen sation provisions of Section 3700 of the Labor Code, I shall <br /> fcrthwth comply with those provisions. <br /> Date: 3^ •Z 3 SlgnaWro: <br /> Printed Name: �v�e �1rc�o/yo A/ - <br /> WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE 13 UNLAWFUL,AND SHALL SUBJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINE'S 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 3746 OF THE LABOR CODE. <br /> f AUTHORIZATION FOR QTR THAN C-57 SIGNING PERMIT APPLICATION <br /> I, (signature efC•57 licensed authorized representative), <br /> hereby authorize(print name) , <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 datvO an ttes front page of this application. <br /> 8-29-02/Ml <br /> LP.UD <br /> MAR 2 1 2333 <br /> GNrv�If ON1 iC U {Itrn�`rl <br />